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The Hillingdon Hospitals NHS Foundation Trust

Meeting of the Board of Directors

Wednesday 26th March 2014, 2.00pm

Board Room, Mount Vernon Hospital

Paper Timings*

a) Introductory business 5 mins

1. Welcome and apologies for absence -

2. Declaration of hospitality or amendments to the Register of Interests -

3. Minutes of the Board meeting held in Public on 26th February 2014

4. Actions Log

5. Declaration of Any Other Business

6. Patient Story and Putting People First Report (TM) 10 mins

7. Chief Executive’s Report (SD) 5 mins

b) Strategy

8. Shaping a Healthier Future: update (KMO) 10 mins

9. North West London Whole Systems Integration (KMO) 15 mins

10. Staff Survey – 2013 Results and Action Plan (CG) 15 mins

11. Embedding of the Trust Core Values (CARES) (CG) 10 mins

12. London Cancer Alliance Membership Arrangements (KMO) 10 mins

c) Quality, Operational & Financial Performance

13. Review of the Trust’s Quality Governance Systems (TM) 5 mins

14. Quality & Operational Performance Report (KMO/TM) 15 mins

15. Financial Report (PW) 20 mins

16. QIPP Update (KMO) 15 mins

17. Revalidation of Medical Staff: Progress Report (AK) 10 mins

d) Regulatory

18. Information Governance Standards 2013/14 Toolkit Assessment Process (DS) 5 mins

e) Other

19. Corporate Communications Report (DS) 5 mins

20. Issues arising from the Board Committees 5 mins

21. Board Committee membership (MR) 5 mins

22. Use of Trust Seal - -

23. Any Other Business - -

24. Questions from the Public - -

Date of next meeting:

• Wednesday 30th April 2014, 2.00pm, Furze Conference Room, Hillingdon Hospital * NB timings are indicative only: the Chair may decide to vary the timings and order.

ITEM 3

Board Meeting in Public 26th March 2014

THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST

MINUTES OF THE MEETING OF THE BOARD OF DIRECTORS HELD ON WEDNESDAY 26th FEBRUARY 2014

IN THE FURZE CONFERENCE ROOM, HILLINGDON HOSPITAL

Meeting held in public

Present:

Katey Adderley (KA) Non-Executive Director Carol Bode (CB) Non-Executive Director Shane DeGaris (SD) Chief Executive Soraya Dhillon (SDh) Non-Executive Director Abbas Khakoo (AK) Medical Director

Karl Munslow Ong (KMO) Chief Operating Officer Theresa Murphy (TM) Executive Director of the Patient Experience &

Nursing Lis Paice (LP) Non-Executive Director Pradip Patel (PP) Deputy Chairman and Non-Executive Director

James Reid (JR) Non-Executive Director Mike Robinson (MR) Chairman

Craig Rowland (CR) Non-Executive Director David Searle (DS) Executive Director of Corporate Development

Paul Wratten (PW) Finance Director

In Attendance: Claire Gore (CG) Director of People David Coombs (DC) Trust Secretary (minutes)

Apologies: None

Also Present: Ned Tapley (NT) Junior Doctor

Graham Hawkes Public Governor Mandy O’Brien Staff Governor Three members of the public

* for item 06/02/2014

ACTION

01/02/2014

MR introduced LP and SDh as newly appointed Non-Executive Directors and welcomed them to the Board.

Declaration of Hospitality

DC stated that the Register of Interests had been updated in line with LP’s and SDh’s entries and was presented later in

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or Amendments to Register of Interests 02/02/2014

the meeting under a separate agenda item.

Minutes of the last Meeting 03/02/2014

The draft minutes of the Board meeting held in public on 29th January 2014 were approved as an accurate record subject to the following amendments: • Page 1 to note that Simon Dowse from KPMG observed

the meeting. • Page 12: second paragraph to refer to ‘high’ rather than

‘significant’ risk. • Page 13: fourth paragraph to be amended to read: ‘KA

said that there was a request from the Committee to have a series of “deep dives” on the Board Assurance Framework…’.

Actions Log 04/02/2014

The Board reviewed the actions arising from the Board meeting held in public on 29th January 2014 and those outstanding from previous meetings. The Board agreed that those actions marked ‘xx’ could be closed. In relation to action 05/01/2014, CG stated that a report will be presented to the next meeting on the impact of CARES. In relation to action 18/01/2014, CG stated that a number of actions have been taken to address the concerns around Statutory & Mandatory Training (STaM) and a report will be presented to a future Board meeting.

Declaration of Any Other Business 05/02/2014

None declared.

06/02/2014 Patient Story and Putting People First TM welcomed Dr Ned Tapley (NT) to the meeting who outlined a patient story to the Board relating to a patient, Mrs R, who was admitted to the Trust with a broken hip. NT stated that he works on Kennedy Ward in a role that has been created to act as a liaison between the Care of the Elderly and Orthopaedic teams. NT highlighted the care provided to Mrs R across several different teams. NT stated that Mrs R made a very good recovery, which was partly due to the close working with therapists who mobilised Mrs R within a few days of the operation. NT stated that the Occupational Therapists worked closely with the patient’s family to ensure support was in place post-discharge.

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NT stated that Mrs R provided very positive feedback on her care. NT stated that key factors in enabling a positive outcome included ensuring good communication with Mrs R’s family. NT stated that an area for further improvement is when a patient is transferred to another team. NT stated that there are also issues with the windows on Kennedy ward, but actions are being taken to mitigate this. CB asked how the Trust can support clinical staff to improve the handover process. NT stated that his role was created to help the process. NT stated that consideration is being given to starting the discharge summary before a patient is transferred to the Care of the Elderly team in order to ensure the information from the orthopaedics team is not lost. PP stated that this was an excellent case study. PP stated that whist the Trust is good at looking after patients, there is a need to be consistent in how patients’ families are involved. PP stated that it is often the small actions that can have a significant positive impact. DS noted the positive impact of the therapy staff mobilising Mrs R within a few days of the operation. DS asked whether the Trust can mobilise patients within the same time-period if the operation occurs on a Thursday or Friday. NT stated that there are on-call therapists who can mobilise patients over the weekend if required. SDh stated that this is an excellent example of joined-up care within the hospital. In terms of joining up care outside the hospital, SDh asked about the communication to GPs and social care. NT stated that the communication with GPs is through the discharge summary, whilst any actions for social care would be passed through the Occupational Therapists. TM thanked NT for attending the meeting. NT presented the Putting People First report that included the Trust’s performance in the Family and Friends Test (FFT). TM highlighted the FFT results by ward and stated that each ward will have a display board that presents their FFT results. TM stated that the Trust has the third highest response rate in the maternity FFT in London and the Trust’s maternity FFT score places it 12th of the 22 London Trusts. TM highlighted the Trust’s results in the national inpatient survey and stated that the Trust has improved in 68 of the 85 questions. TM stated that a report on the results will be presented to the Board once the national benchmarking is available.

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TM highlighted the work that has been undertaken to improve the Trust’s management of complaints, as outlined in the report. MR stated that these improvements were extremely welcome. CB referred to the FFT results by ward and asked whether the reasons for some wards having consistently high scores have been identified. CB suggested this data is triangulated with other information. TM stated that the high performing wards on the FFT are those where the ward staff have brought into the value of the FFT and there is good leadership. KA stated that the Trust is actually the highest performing Trust on the maternity FFT in London amongst those with a response rate of over 20%. KA stated that it is important to consider how the FFT is completed and ensure that this is undertaken independently by patients. TM stated that the Trust continues to refine the process for completing the survey and is increasingly encouraging patients to complete the form online in the privacy of their home once they are discharged. LP asked whether the patient feedback has been triangulated with staff feedback and that from junior doctors in the GMC survey. TM stated that this is taking place and stated that similar issues have been raised across these sources of information, in particular around staffing levels. SDh stated that it is important to examine whether there are differences in patient feedback across different demographic groups. TM stated that this will be an increasing area of work for the Trust’s Experience & Engagement Group (EEG). The Board noted the report.

07/02/2014

Shaping a Healthier Future – Progress Update KMO presented the report that provided an update on the implementation of the ‘Shaping a Healthier Future’ (SaHF) programme at the Trust. KMO stated that the central review process of Trust Outline Business Cases (OBCs) is due to begin shortly, with these potentially being signed off in May. KMO highlighted the patient and public engagement work being undertaken and that proposed in relation to the SaHF programme. CB asked whether the Trust’s engagement is joined up with that being undertaken by other health organisations; CB stated that multiple organisations could potentially be approaching the same groups and individuals. KMO stated

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that the SaHF programme team are seeking to coordinate public engagement and will be coordinating the public engagement activities and for example are leading public engagement on the travel implications of SaHF. KMO stated that the SaHF programme team are also assisting Trusts with the equality impact assessments of the business cases. CB noted that much of the Trust’s engagement is being undertaken through the Governors and stated that there is also scope to undertake engagement with other groups and members of the public through mechanisms such as Healthwatch. SD stated that the Governors have been involved in order to commence the public engagement within a short timescale but agreed that it would be helpful to have wider engagement. PP stated that SaHF is a major change programme for the Trust and stated that it is important to engage the Gazette so that the newspaper can help inform the public on the changes at the Trust. SDh stated that local people will want to know what is happening at their local hospital and what this means for them. SDh stated that the Trust’s website does not currently include this information on the high level strategic changes that are taking place. SD stated that this information has been articulated in various meetings and forums. SD stated that whilst he believed it was currently on the website, this would be re-examined to ensure it is sufficiently visible. The Board noted the report.

08/02/2014 Leadership Strategy Progress Update CG presented the report that provided an update on the implementation of the Trust’s Leadership Strategy. CG highlighted that the Trust has successfully obtained external funding for a number of the initiatives in the strategy. LP congratulated CG on gaining external funding and having a coherent strategy in place. LP stated that much of the strategy is aimed at clinicians, which is positive, but asked whether the Trust is developing non-clinical managers. CG confirmed that the Leadership 100 Programme includes non-clinical leadership. However the report emphasises the work on clinical leadership given that the leadership diagnostic identified that there are gaps around the clinical leadership at the Trust, and that the Trust is seeking to move towards being a clinically led organisation. LP asked what good would look like in a couple of years in terms of clinical leadership. CG stated that this would involve clinicians developing business cases and managing change.

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CB stated that the Board has not yet seen the total tangible and intangible investment in the strategy to date, and the tangible impact of this. CB asked how the impact of the investment will be measured and when this will be reported to the Board. CG stated that the first cohort only started the leadership programme in September and therefore it is too early to measure the impact. CG stated that once this cohort has completed the programme then the impact could be measured. LP asked how the Trust will measure the impact on the individuals who attended the programme. CG stated that this will not be measured on an individual basis, but through a future diagnostic of the organisation. KMO stated that this links to the wider work on developing the clinical leadership structures at the Trust, which will be subject to a forthcoming Board paper. SD stated that LP and CB had raised valid points and stated that CG and Executive colleagues will need to clarify what good looks like and have tangible measures of success, and incorporate this into the work on clinical leadership structures. The Board noted the report.

09/02/2014

The Interface Between Nursing and Estates & Facilities DS presented the report that as requested by the Board, outlined the actions being taken to address the estate related issues identified in the recent Care Quality Commission (CQC) inspection, in particular how the wards/clinical areas and the Estates & Facilities department work together. SD stated that the Trust is on a ‘journey’ and the proposals in the report seek to enhance the existing arrangements in place to ensure ward managers are appropriately supported. SDh stated that patient experience is the Trust’s highest priority and asked whether there is a phased multi-year programme of work that would positively impact on the patient experience. DS stated that the Trust’s Patient Led Assessment of the Care Environment (PLACE) assessments and action plan drive the estates and facilities plan for the year ahead. SD stated that this report is about the day to day maintenance of the site, rather than the major programme of capital investment. SDh stated that it is important to empower ward staff so that they are able to identify the two or three changes that would make the biggest difference to the patient experience. MR stated that this was a good report; however it is important to reflect on the strategic issue about the lack of capital

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resources to undertake the required level of works on the Trust’s estate. MR stated that there are issues around how reactive maintenance at the Trust is organised and the relationships between the nursing and estates departments. MR stated that if work cannot be carried out because there are insufficient resources, then the issue should be escalated to the Board so that the Board can decide on the prioritisation of resources. MR stated that the fact the report follows a CQC report and feedback from Healthwatch indicates that the previous arrangements for maintaining the estate had deficiencies. LP highlighted the benefit of walkabouts by the estates department to proactively identify estate issues as this would prevent clinical staff from being distracted by having to deal with estates issues. DS stated that as outlined in the report, walkabouts will be taking place and stated that the Trust’s Experience & Engagement Group (EEG) will be a key method for driving this forward. MR highlighted the importance of the partnership between the nursing and estates staff on the ground. The Board: 1. Noted the report and welcomed the progress in

strengthening working arrangements between the departments.

2. Supported the strengthened governance plans and review of estates supervisory resource.

3. Supported the initiative to improve communication of repairs progress.

10/02/2014 Quality and Operational Performance Report

KMO presented the quality and operational performance report for January. KMO highlighted the significant non-elective activity pressures on the Trust in January but stated that the Trust was the second best performing acute Trust in London on the A&E four hour target for all types of attendances. KMO praised the work of the clinical teams in achieving this. KMO stated that the Trust continues to remain green on the Monitor scorecard, and has maintained this position for over two years. KMO highlighted the quarterly update on cancer services, and stated that the changes to the London Cancer Alliance will be subject to a further Board report. KMO stated that the findings of the peer review will be presented to the Quality & Risk Committee. KMO highlighted that the Trust continues to undertake non-

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elective and elective activity for North West London Hospitals NHS Trust at Mount Vernon. KMO highlighted that this work is being undertaken without detrimental impact on Hillingdon residents. SD highlighted that this is part of the Trust’s strategy of maximising income from other commissioners, given Hillingdon Clinical Commissioning Group’s (CCGs) constrained financial position. JR noted and welcomed that the Trust is one of the 17 Trusts nationally whose Summary Hospital-level Mortality Indicator (SHMI) is in the ‘lower than expected’ banding. JR stated that it was also interesting to note the readmissions rates at other Trusts in North West London. JR stated that whilst the Board has been concerned about the Trust exceeding this target, only one Trust is meeting the target. JR asked when the findings of the Trust and CCG readmissions audit will be available. KMO stated that the report is currently in draft form and the findings are currently being evaluated with partners. KMO stated that there are no major surprises in the report and the work on integration that is underway will help address these issues. TM stated that there was one case of c-diff in February which brings the Trust to a total of 12 for the year. TM stated that the Trust is still on course to remain within the trajectory of 14 for the year. TM stated that it is disappointing that the falls rate has increased and assured the Board that a root cause analysis is undertaken on every fall. TM stated that there have also been five grade 3/4 pressure ulcers; TM stated that these have been examined and a report on the learning will be presented to a Board Seminar. AK stated that from next month the Board report will include the weekday and weekend Standardised Mortality Ratio (SMR) for London hospitals. KA noted that sickness absence in the Women’s & Children’s Division is higher than in the rest of the Trust. CG stated that this has been examined and action will be taken in the relevant cases as appropriate. PP stated that whilst the Trust’s palliative care coding rate was previously lower than the national average, the proportion of deaths coded as palliative care is now higher than the national average. AK stated that a close watch is being kept on this. AK stated that the new mortality review process under which every death is reviewed by a Consultant will give assurance that the coding is correct. PW stated that the Trust’s c-diff performance in January and February was very positive with only one case across the two

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months. PW stated that the winter period often sees an increase in the number of cases and asked whether the Trust did anything different this year. AK stated that norovirus often leads to an increase in c-diff, however norovirus rates across London have been lower than average this winter. TM stated that the Trust has also been focusing on anti-microbial prescribing. SD highlighted the number of c-diff infections at the Trust has halved compared to last year. SDh stated that it was an extremely comprehensive report and one of the best she had seen to a Board. SDh stated that the only addition would be to include triangulation with staff comments in line with the Berwick report. CG highlighted that the national staff survey results will be reported to the Board next month. MR stated that this data is retrospective and real-time feedback from staff would be invaluable. SDh noted that the medical appraisal rate currently stands at 51%, and stated that this is disappointing given the importance of appraisals to revalidation. CG stated that the target is to reach 100% by the year end. The Board noted the report.

11/02/2014 Financial Report PW presented the finance report for January and stated that at the end of January 2014 the Trust had a cumulative surplus of £0.5m, which was on plan. PW stated that the Trust is on track to exceed the financial plan due to the financial risks being on the upside and the income from Edmunds Ward. KA stated that the £8m of transitional funding in the contract with the commissioners was based on activity reducing. KA asked whether activity has reduced or whether the £8m of income will turn out to be payment for activity. PW stated by year-end it is anticipated that £4.5m would be income, with £3.5m as transition funding. KMO stated that the growth in activity has been stemmed in some areas, whilst activity has reduced in others. SD stated that the Trust has started to revise pathways, and whilst these have not had the impact on the level of hospital activity planned by the CCG, the activity trend is moving in the right direction. The Board noted the report.

12/02/2014 QIPP Report KMO presented the update on the 2013/14 QIPP programme and stated that in month ten the QIPP programme achieved £784k of savings against a revised plan of £840k. KMO stated

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that the Trust is still forecast to achieve the revised ‘likely case’ forecast of £8m. KMO highlighted the planning that is underway for next year’s QIPP plan, including the regular meetings with Hillingdon CCG. KMO stated that currently £6.1m of savings have been identified and the validation process is currently underway. KMO stated that the Trust has been very prudent on the income generating schemes, and any likely upside would help offset any downward shift on the savings schemes following the current scrutiny. KMO stated that the QIPP plan will be brought to the Transformation Committee’s next meeting for a ‘deep dive’. CR stated that the fact the Trust is on track to deliver the revised forecast of £8.1m this year gives confidence that the Trust will achieve next year’s plan. PW stated that the savings delivered as a percentage of costs puts the Trust in the top quartile of Foundation Trusts. MR congratulated the team for the delivery of the savings this year. KMO stated that the Trust will seek to apply the Programme Management Office’s (PMO) change management disciplines to the CCG QIPP schemes and other Trust schemes such as service developments. MR noted the good work with the CCG on the shared QIPP schemes and stated that there is a need to improve the visibility of this work at the Board. SD highlighted that the target of £9m savings for next year is contingent on the current assumptions around the contract with the commissioners, and the target may have to be revised in light of the outcome of these negotiations. The Board noted the report.

13/02/2014 Updated Standing Financial Instructions and Scheme of Reservation & Delegation PW presented the updated Standing Financial Instructions (SFIs) and Scheme of Reservation & Delegation (SRD) for the Board’s approval, following review by the Audit & Assurance Committee (AAC). PW highlighted the minor amendments to the documents since the AAC. MR stated that as outlined in a briefing circulated by DC prior to the meeting, one further amendment to the Scheme of Reservation & Delegation is proposed. MR stated that Monitor have recently published a revised edition of the Code of Governance for NHS Foundation Trusts, which states: "The Board of Directors should not agree to a full-time Executive

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Director taking on more than one Non-Executive Directorship of an NHS Foundation Trust or another organisation of comparable size and complexity, nor the chairpersonship of such an organisation." MR stated that to ensure compliance with this provision, it is proposed to move the following clause from the Remuneration Committee’s terms of reference and add this to the Scheme of Reservation for the Board: "In the event of such case arising, to authorise an Executive Director taking on a non-executive directorship of an NHS Foundation Trust or organisation of similar size and complexity." The Board: 1. Approved the updated Standing Financial Instructions and

Scheme of Reservation & Delegation subject to the addition of the clause outlined by MR above which would then be removed from the Remuneration Committee terms of reference.

2. Agreed that the updated Standing Financial Instructions and Scheme of Reservation & Delegation would be reviewed on an annual basis by the Audit & Assurance Committee (AAC).

DC

14/02/2014 Register of Directors’ Interests The Board noted the updated Register of Directors’ Interests and confirmed that there are no material conflicts of interest on the Board. JR highlighted that the Register incorrectly identifies himself as Deputy Chair rather than PP and stated that this needs to be corrected.

DC

15/02/2014 Nomination of a Procurement Non-Executive Director PW presented the report that asked the Board to nominate a Non-Executive Director (NED) to act as a link with the national procurement development team. PW stated that the request for such a nomination is one of a number of issues outlined in a joint letter to Trusts from Monitor and the Department of Health. PW stated that the Trust’s procurement team will be taking forward the other issues in the letter. MR proposed that given his commercial experience, PP is the Trust’s nominee. The Board: 1. Noted the issues for attention contained in the joint

Department of Health and Monitor letter on national procurement development.

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2. Nominated Pradip Patel as the Trust’s link to the national procurement development team.

16/02/2014

Issues Arising from the Board Committees CR provided a verbal update on the Transformation Committee’s meeting on 10th February. CR stated that the Committee received a summary update on the site strategies for Hillingdon and Mount Vernon, and also the draft capital plan. CR stated that PW was asked to provide to a future Committee meeting a briefing on how the investments in the informatics strategy contribute to transformation. CR stated that the Committee also received an update on proposals for increasing car-parking capacity at Hillingdon hospital and stated that a paper on this will be coming to the Board in March.

17/02/2014 Use of the Trust Seal There was no use of the Seal to report.

18/02/2014 Questions from the Public Mrs Thomas stated that her husband has been on Kennedy Ward since 15th February. Mrs Thomas raised concerns around the hospital’s communication with carers and stated that she has not been updated on her husband’s condition despite frequent requests to meet with the Doctor on call. Mrs Thomas stated that her husband had previously been discharged from another hospital and transported home by patient transport at 11.30pm. Mrs Thomas stated that she wanted assurance that THH would not have done the same and that there is a cut off time after which a patient will not be discharged and transferred by patient transport. Mrs Thomas stated that the nursing staff have been excellent on Kennedy Ward but highlighted the issue of the windows on the ward and the length of time it took for a gap to be repaired with tape. Mrs Thomas stated that this links to the earlier discussion about the relationship between the nursing and estates staff. Mrs Cook noted Mrs Thomas’ comments about the medical staff and stated that complaints about the attitude of medical staff are the most common subject of complaints to the Trust. Mrs Cook asked about the action being taken in respect of call bells. DS stated that there is a programme of work taking place between January and March totaling £35k in A&E and Kennedy Ward. DS stated that a further programme totaling £110k is planned for next year, with further phases in subsequent years.

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Mrs Cook asked how financial donations given to the Trust following a funeral are spent. PW stated that these would be donated to the Trust’s charity and accounted for separately to the Trust’s main income. PW stated that the Charitable Funds Committee oversee how such funds are spent and approve requests from the ward teams on how they are to spent in order to benefit patients and staff. Mrs Cook asked about the transfer of medical records to Heston and whether these would be secure. KMO stated that the Trust is in the process of establishing a new storage facility at an off-site location due to the lack of suitable facilities at Hillingdon hospital. KMO stated that all standards around Information Governance will be met and the transfer will ensure the records are kept in a better location. Mr Bartram stated that he recently visited a friend on Edmunds Ward and stated that he was a little disappointed that visitors were not offered a cup of tea during the ward rounds. SD stated that he was not aware that this was an official policy; TM stated that she would investigate this further. Mr Bartram stated that it was positive to hear about the action being taken about the estate earlier in the meeting. Mr Bartram stated that staff are often not aware of issues around the outside of the estate so it is important to ensure such issues are identified. DS stated that a civil engineering firm undertakes a comprehensive survey of the site to make sure the Trust is aware of the risks. However it is challenge to manage the site within the available resources. Mr Bartram reported a situation that arose when he visited an elderly patient and the nurse asked the patient a question of a personal nature in front of him. Mr Bartram stated that the nurse should have asked him to leave the bedside so the question could be asked. TM agreed that this should not have happened and stated that promoting privacy and dignity is a key aspect of her ward rounds.

19/02/2014 Any Other Business There was no further business to discuss.

Date of Next Meeting The next meeting is scheduled to take place on Wednesday 26th March, at 2.00pm in the Board Room, Mount Vernon Hospital.

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Mike Robinson Date Chair ………………………………. …………………

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ITEM 4 Actions arising from Board Meetings held in Public 2014 Note: actions marked ‘xx’ are proposed for Board sign-off as completed. February 2014 Action ref: Action Action

with Target date to complete

Progress/evidence that completed Board confirmed completed

13/02/2014 Updated Standing Financial Instructions and Scheme of Reservation & Delegation

Scheme of Reservation & Delegation and the Remuneration Committee terms of reference to be amended as per the minutes.

DC March 2014

Done. Documents updated accordingly.

XX

14/02/2014 Register of Directors Interests

Designation of the Deputy Chair to be corrected in the Register.

DC March 2014

Done. Register updated accordingly. XX

January 2014 Action ref: Action Action



05/01/2014 Patient Story and Putting People First Report

Impact of CARES to be periodically reported to the Board.

CG March 2014

Done. Report presented to the March Board.

XX

18/01/2014 Integrated Risk Register

CG to report to Board on the action being taken to address the risk around STaM.

CG April 2014 Report scheduled for April Board.

December 2013 Action ref: Action Action



10/12/2013 Meeting Nutritional Needs in Hospital

Board to receive an annual report that includes information on the impact and effectiveness of the Trust’s processes to support patients’ nutritional needs.

TM June 2014

Scheduled for June 2014.

November 2013 Action ref: Action Action



08/11/2013 Dementia Strategy

Evaluation of progress in delivery of strategy to be presented to the Board.

TM April 2014 Evaluation of progress to be presented to the Board in April 2014.

September 2013 Action ref: Action Action



08/09/2013 London Health Programmes Quality & Safety Programme Acute Emergency and Maternity Services Standards

Progress in the delivery of the standards to be monitored through either the Transformation Committee or Quality & Risk Committee, with this to be finalised outside of the meeting following a discussion between the Committee chairs.

RGM

JR / CR

April 2014 Agreed that progress will be monitored through the Quality & Risk Committee. Next update proposed for April 2014.

10/09/2013 Safeguarding People Annual Report

Board to receive quarterly updates on safeguarding training uptake until performance improves.

CG Dec 2013 December 2013: Safeguarding adults: 74% Safeguarding children: Level 1: 67% Level 2: 70% Level 3: 48% March 2014 Safeguarding adults: 68% Safeguarding children: Level 1: 66% Level 2: 54% Level 3: 47% There has been a reduction in the reported uptake due to the Trust recently aligning to the Core Skills Training Framework (CSTF), which is a national programme being rolled out across England (region by region, starting with London).

12/09/2013 Revalidation of the Trust’s Medical Staff

(b) Board to receive six monthly progress updates on revalidation.

RGM / AK

March 2014

Done. Report provided in March 2014 and scheduled on the Board planner on six-monthly basis.

XX

13/09/2013 Research & Development Annual Report

Trust’s Research & Development Strategy to be reviewed and presented to the Board, with consideration given to increasing the role of non-medical staff on research and development.

RGM / AK

Sept 2014 Proposed to be presented as part of the next report in September 2014.

16/09/2013 QIPP Report

(a) Board to review whether Newton delivered what was outlined at the outset, and if not, to explore the reasons why.

KMO March 2014

Rescheduled for the March Board Strategy Session given end-date for Newton supported schemes. Update for March Board: Post implementation review meeting being held with Newton on 19th March. Summary report will be shared with Trust Board in Quarter 1 2014/15

(b) Board Strategy Session to review the work being undertaken

SD Nov 2013 Done. Paper presented to the March Board Seminar.

XX

Action ref: Action Action with

Target date to complete


to move the Trust towards a clinically led organisation.

May 2013 Action ref: Action Action



15/05/2013 Quality & Operational Performance Report

(b) Rolling two year trend to be provided for the workforce indicators included in the workforce strategic trend analysis.

CG TBC Update to March Board: Feedback received from the NEDs in March; dashboard to be reviewed with the Head of Workforce Planning when appointed.

ITEM 6 Board Meeting in Public

26th March 2014


REPORT TO: Trust Board REPORT FROM: Bev Hall, Deputy Director of Nursing REPORT SPONSORED BY: Theresa Murphy, Executive Director of Nursing and

the Patient Experience DATE: 26th March 2014 SUBJECT: Putting People First Report Trust Strategic Priority • To create a patient centred organisation, to deliver improvements in patient

experience and the quality of care we provide. Summary This report provides the Friends and Family Test results for all participating ward/department areas. Any themes are highlighted and a brief summary of the comments received and some of the planned actions are also described. The report also provides highlights from the 2013 Picker Inpatient Survey. Board Action Required The Board is asked to note and comment on the report. Equality Impact Assessment: There is no positive or negative impact from this report.

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Putting People First Report

1. Friends and Family Test Objective: To implement the standardised Friends and Family Test Question in order to understand what matters to patients and benchmark patient experience. The Friends and Family Test (FFT) was implemented across all inpatient wards and the A&E department in April 2013 and Maternity in September. FFT scores are calculated by using the proportion of patients who would strongly recommend minus those who would not recommend or who are indifferent. The results for February 2014 are shown below.

April May June July Aug Sept Oct Nov Dec Jan FebSeries1 53 52 61 59 57 58 63 65 62 63 61

0

10

20

30

40

50

60

70

Friends and Family Test - Trust Score

The Friends and Family Test Score for the Trust (Inpatients, A&E and Maternity combined) is 61.This is based on 1099 responses. More detailed information about each group is contained below.

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Friends and Family Test Score for A&E

The Friends and Family Test score for A&E in February is 55; this is a decrease of 6 compared to the previous month. This is based on 362 responses. This gives a response rate of 20.5%. The distribution of responses across each possible answer is shown in the graph above. Friends and Family Test Score for Inpatients

The Friends and Family Test score for inpatients in February is 64, no change from the previous month. This is based on 493 responses. This gives a response rate of 35%. The distribution of responses across each possible answer is shown in the graph above. The table below shows the FFT score by ward, the table is organised in descending order. Please note that the monthly movement refers to the score:

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Ward FFT Score Monthly

Movement Response rate (15% target)

Number of responses

Alderbourne 100 116% 7 CCU 100 25% 6 Trinity 87 78% 73 Bevan 86 29% 21 Drayton 82 45% 34 Observation ward 71 15% 20 Jersey 66 38% 57 Lister* 66 11% 6 Hayes 64 50% 27 Marina 64 9% 12 Churchill 60 69% 16 Edmunds 55 10 Pinewood* 53 51% 17 Kennedy 46 47% 81 EAU 45 29% 21 Grange 43 24% 22 Stroke 41 67% 19 * Extra capacity wards

• Seven wards increased their score • Nine wards had a lower score • Two wards had a response rate less than the target of 15%

A selection of comments from the February survey are shown using the ‘Never and Always’ events framework. Never Events - attitudes and actions that

patients should never experience Always Events – attitudes and actions that patients should always experience

1 Only problem that I could raise was noise, but I was aware that this couldn’t be helped. .

Nurse explained procedures and care very well. Care well maintained throughout stay.

2 Some doctors were compassionate but quite a few were dismissive and borderline abrasive.

Nursing staff were considerate and for the most part highly attentive and compassionate despite being very busy. The ward was always hygienic and clean, as are the entire team. Housekeeper and food server were prompt and very helpful with advice on meals- but the food left much to be desired

3 A couple of time I was told one thing but another thing happened.

Everything was excellent, saw matron and had a nice conversation with her. Nice to see good matrons on the ward. Staff so caring. Thank you

4 More staff to help with toileting. Good, loving attention at all times. An air of great happiness in the ward. Thanks to an understanding sister. I would call it a real A team.

5 Discharge could be quicker Very friendly staff, very attentive and responsive to any request. Work extremely hard for very long hours. The ward is clean and tidy, I have no issues about the ward but the staff work so hard, maybe more staff could ease their workload.

6 Having had the misfortune of having items lost in great haste of transfer. Care could be improved by not thrusting patients to 5 wards in 5 days

Wonderful friendly and helpful staff. Really can’t fault them or thank them enough for their care and attention. They made a daunting and scary situation much easier to cope with. Thank you

7 Everyone is rushing everywhere and just don’t seem to sit and talk and listen

Observed on a regular basis and was asked on many occasions how I was feeling

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Most comments are very positive. It is pleasing to see comment 3 about the visibility and accessibility of matron at ward level and comment 6 describing the difference staff can make to patients who are feeling vulnerable. Comment 7 (always) is a reflection that our proactive care approach is working well on this particular ward. Comment 7 (never) will be explored with the sister on this particular ward; the comment may be a reflection of staffing or an increased dependency at the time of surveying or attitude and behaviour. Comment 6 (never) reflects the impact on the patient of multiple ward moves, loss of property is unacceptable and a memo will be sent to all sisters and matrons regarding safe keeping of property. This will also be discussed at the monthly Care Accounts meeting. . Friends and Family Test for Maternity The Friends and Family Test was implemented in Maternity in September. The question is asked at four key touch points: antenatal care, labour/birth, postnatal ward and community postnatal care. The February maternity FFT scores and response numbers and rates are shown in the table below. Please note labour/birth number of responses includes labour ward, home births and Katherine birthing unit. Touch points Score Monthly

Movement Response rate Number of responses

Antenatal (36 weeks) 71 13% 34 Labour/birth 68 28% 87 Postnatal ward 60 28% 89 Postnatal community service

45 10% 30

The highest scores are reported in the labour/birth section and antenatal service. Response rates are lower during antenatal care and once a mother leaves the hospital. In total only 5 women out of the 240 women who responded this month gave a negative response; 3 neither likely or unlikely and 2 unlikely. The comments associated with these negative scores are shown in the never events column below will be scrutinised to gain insight into what is important to mothers

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Response Distribution

The distribution of responses for each touch point and across each possible answer is shown in the graph above. The table below highlights some of the comments from the maternity FFT. Comments indicating that improvement is

required Positive Comments

1 I saw over 7 different Consultants and registrars so no continuity of care

We received brilliant support and care from all the midwives, doctors and paediatricians, with breastfeeding and were allowed to stay on the ward until success was achieved.

2 I didn’t see the same midwife which wasn’t good I was checked on regularly and kept informed. Friendly staff and comfortable environment

3 A bit more privacy would be nice. Listened to at all times and collected a thorough history 4 Midwives need to do more than just observations,

they should be asking questions and checking baby. Pain medication should be offered as soon as patient has had appropriate time intervals as a patient who is in pain has no idea what they have already had.

Nurses were lovely and made me feel at ease. They made a scary and painful time more bearable. A very happy mum and baby.

5 Due to a complicated history, a care plan was drawn up in advance to voice my concerns but this was completely ignored at the time of delivery.

Midwives and doctors were all extremely helpful and reassuring. I was very happy with my care. Staff made my experience of having this baby after a still birth a very positive one

Continuity of care has featured as being of importance to mothers this month and this has also arisen previously. Pain relief and privacy have also been highlighted have by two mothers. This will be discussed at the Experience and Engagement Group (EEG) meeting on 13th March where maternity services are presenting feedback results from all sources and describing their improvement work. It may be helpful to undertake a more focused piece of work to help gain greater insight into these two important issues from the mothers perspective.

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Sharing our results Following a discussion at the recent EEG, we will be working with the Communication Department and others to identify the best way to share our results with patients, stakeholders and staff. 2. Four Investigation reports concerning the University Hospitals of

Morecambe Bay NHS Foundation Trust Parliamentary and Health Service Ombudsman (PHSO) February 20141.

Objective: To share the key learning and messages from the recent PHSO report On 27th February the Parliamentary Health Service Ombudsman published a report into complaints concerning events that took place at University Hospitals of Morecambe Bay NHS Foundation Trust. Their investigations were not into the care of the baby, but about the handling of complaints following this avoidable death. The complaints investigated focused on inappropriate email exchanges, the investigations the Trust carried out into the death of the baby and an allegation of collusion amongst midwives about the fluctuation of the baby's temperature in preparation for the inquest. Their investigations found that the hospital did not answer the family’s questions openly and honestly and did not learn from what it found. This is particularly unacceptable when an avoidable death was the cause of the complaints. The fact that the early records were missing compounded the problem. The complaints demonstrate that a lack of openness by the Trust and the quality of their investigations of these complaints caused a loss of trust and further pain for the family. The PHSO explains that although the previous ombudsman declined to investigate the father’s first complaint, in light of new evidence from the coroner’s inquest, it was later accepted for investigation of the elements of this original complaint that were still outstanding. They acknowledge that had they investigated earlier the family might have had answers to some of their questions regarding what happened to their baby sooner than they did. They apologise for the impact of this. The results of these investigations reinforce the need for change in hospitals. Cultural change is needed from the ward to the Board. Strong leadership is necessary to encourage openness and learning, the report also highlights the need to overcome the defensive response of hospitals to complaints. The report recommends that Hospital Boards should:

Establish expectations of openness and honesty, seeking feedback in order to learn and improve. They should reward staff who seek and respond well to concerns and complaints, including acknowledging mistakes. This will foster a new culture of remedy and learning.

Use the ability within the complaints regulations to commission independent investigations if:

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'a complaint amounts to an allegation of a serious untoward incident;

the subject matter involving clinically related issues is not capable of resolution without an expert clinical opinion;

a complaint raises substantive issues of professional misconduct or the performance of senior managers;

a complaint involves issues about the nature and extent of the services commissioned.'

This report will be shared more widely with staff who are involved in the investigation of complaints and the key learning points will be distilled and included in a workshop being developed to support investigation leads. The Complaints Policy will also be reviewed to ensure that the recommendations reflected in this and several other reports highlighted in previous Putting People First papers are incorporated.

1 http://www.ombudsman.org.uk/reports-and-consultations/reports/health/four-investigation-reports-concerning-the-university-hospitals-of-morecambe-bay-nhs-foundation-trust

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http://www.ombudsman.org.uk/reports-and-consultations/reports/health/four-investigation-reports-concerning-the-university-hospitals-of-morecambe-bay-nhs-foundation-trust

http://www.ombudsman.org.uk/reports-and-consultations/reports/health/four-investigation-reports-concerning-the-university-hospitals-of-morecambe-bay-nhs-foundation-trust


26th March 2014


REPORT TO: Trust Board REPORT FROM: Shane DeGaris, Chief Executive DATE: 26th March 2014 SUBJECT: Chief Executive’s Report Trust Strategic Priority: The report is relevant to all of the Strategic Priorities. Summary: The attached report updates the Board on a range of issues including local, regional and national strategic developments, recent publications, and developments at the Trust not otherwise covered in the Board papers. As such, it seeks to provide context to the Board’s discussions. Board Action Required: The Board is asked to note and comment on the report.

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Chief Executive’s Report

1. Finance and performance At the end of month 11 the Trust continues to sustain its strong performance against the Monitor access and quality indicators. In addition, the Trust is now forecasting it will achieve a better financial position at the year-end than its approved plan. This is primarily due to the additional contracts it has been awarded in the last quarter of the financial year to help North West London Hospitals NHS Trust manage both its elective and non-elective capacity over the winter. The Trust is set to deliver a modest non-recurrent surplus of around 0.5% of turnover that can be used to increase the size of the 2014/15 capital investment plan. At the time of writing this report the Trust’s contract with Hillingdon CCG had not been agreed and neither had the linked bid for ‘Shaping a Healthier Future’ related fixed cost transitional support. To close the gap and to be able to set a balanced 2014/15 budget £5m more revenue funding needed to be identified and agreed. This is clearly the priority task for the management team. 2. Changes at the Trust Trust Chair This is due to be Mike Robinson’s last meeting as Trust Chair as he retires from this position on 31st March 2014. Mike has been with the Trust since 2009 and has led the Board through a number of achievements, including authorisation as a Foundation Trust in 2011. On behalf of the Board, I would like to thank Mike for everything he has done for the Trust and I am sure we wish him a very happy retirement. Council of Governor elections The 31st March 2014 also sees the end of the term of office of our first set of Foundation Trust Council of Governors. The elections process for our next set of Governors has now concluded. Our new Governors are outlined below: Public Constituency North Graham Bartram Public Constituency North Ian Bendall Public Constituency North David Bishop Public Constituency North Tony Ellis Public Constituency Central Harkishan Chander Public Constituency Central Don Dakin Public Constituency Central Neil Fyfe Public Constituency Central Roger Shipton Public Constituency South John Coleman Public Constituency South Keith Saunders Public Constituency South Rekha Wadhwani Public Constituency South Doreen West Staff Constituency Doctors & Dentists Alvan Pope (elected unopposed)

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Staff Constituency Nurses, Midwives & HCAs Mandy O’Brien (elected unopposed) Staff Constituency Allied Health Professionals Graham Coombs Staff Constituency Support Staff Paul Cornford (elected unopposed) Staff Constituency Support Staff Jack Creagh (elected unopposed) Three positions were unfilled (Public Constituency Rest of England, and two to represent the Staff Constituency Nurses, Midwives and HCAs). The nominations for these positions reopened on 17th March. I am sure that the Board will wish to join me in thanking our departing Governors for their contribution and welcome our new Council. 3. Regulatory update: Monitor The Trust has received its confirmed risk ratings for quarter three from Monitor: • Financial risk rating – 3 • Continuity of services risk rating – 4 • Governance risk rating – Green Review of the Foundation Trust sector – nine months ended 31st December 2013 Monitor has recently published its review of Foundation Trust (FT) performance at the end of Q3. Some key points include: • Whilst the majority (74%) of the FT sector is rated ‘green’ for governance, the

acute sector has the poorest governance risk profile: 27% of all acutes and 30% of small acutes are rated ‘red’.

• In terms of operational performance, Monitor note that 28 FTs failed the four hour A&E target in Q3 compared to 11 FTs in the previous quarter. Overall in Q3 95.2% of A&E patients at FTs waited four hours or less. The FT sector achieved the performance standards for all cancer waiting time targets for the quarter, however performance against the 62 day wait from GP referral target has reached the lowest level in two years.

• In terms of financial performance, FTs made a net surplus of £135m in the first nine months of the financial year £38m worse than planned. Although the FT sector as a whole remains in surplus, the size of surplus has more than halved since this time last year. There continues to be differences in financial performance between types of FT, with the acute sector continuing to be the most financially challenged and being in a net deficit position throughout the financial year. Small and medium sized acute FTs are the worst performing financially with EBITDA (earnings before interest, tax, depreciation and amortisation) margins of 3.5% and 4.3% respectively for the year to date.

• The average Continuity of Services risk rating for the acute sector was 3.2, (which was also 3.2 for both small and medium sized acutes).

• Across the FT sector, delivery of efficiency savings through cost improvement programmes (CIPs) was 18% below plan. Efficiency savings as a percentage of controllable savings was 2.9% in the year to date, which compares to 3.2% at the same point last year.

• Across the FT sector capital spend was 24% under plan, with only large acutes across the FT sector achieving their planned capital expenditure. Across the

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sector as a whole, Monitor note that ‘a very high proportion of capital expenditure is on land and buildings compared with IT and equipment’.

4. NHSLA assessment

The Trust was assessed against the NHS Litigation Authority Standards (NHSLA) on 11th and 12th March and has been the awarded the Level 2 Standard. To achieve the higher level 2 in the NHSLA standards, the Trust was able to provide evidence that all staff are working collectively to the practices described in its policies, procedures and clinical guidelines. The Trust will receive a formal report that will outline how it can further strengthen its arrangements. A big thank you to everyone for all the hard work undertaken to achieve this significant outcome.

5. Secretary of State’s message to NHS staff on supporting compassionate

care

The Rt Hon Jeremy Hunt MP, Secretary of State for Health has published his latest message to all staff in the NHS outlining changes which will be made to support staff to deliver compassionate care:

“One year on from Francis, my top priority remains to support you in creating a more patient-centred, compassionate NHS. So this week I have written to all NHS Trusts to reiterate how strongly I feel that staff should be able to raise any concerns about patient care and safety. We have put in place reforms to give you that reassurance, but in light of recent media reports I want it to be absolutely clear that whistleblowers speaking out about poor care should be confident they will be listened to. To support you in this we have made a number of important changes. We have ensured that all NHS employment contracts include the right to raise concerns about care and amended the NHS Constitution to strengthen the commitment to supporting staff who do so. We are also funding a national helpline – independent from employers and the Department of Health and completely confidential – to provide advice to anyone in health or social care who wants to raise a concern. The number is 08000 724 725. We are also introducing a new duty of candour, so that when things go wrong, organisations have a duty to admit mistakes and tell patients what has happened. The professional regulators will be working together to include a new consistent professional duty of candour in codes of conduct. Together, these changes are intended to support you by building the open culture we need and where you can be confident that you can speak up for the patients in your care. Finally I’d like to thank everyone who has been part of a magnificent NHS response to the recent floods. This has been the wettest winter in nearly 250 years, and I know from my own constituency that NHS services have been providing vital help to communities in affected areas.”

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6. Update from Imperial College Health Partners

Imperial College Health Partners, of which the Trust is a member, has appointed Sir Peter Dixon as its Chair with immediate effect. Sir Peter takes up the post after Lord Ara Darzi stepped down from chairing the Partnership in October last year to lead the London Health Commission. Sir Peter is a former Chair of University College London Hospitals NHS Foundation Trust and one of the founders of UCLPartners.

7. Emergency care reconfiguration project update

Kier started on site on 6th January 2014 and the demolition of buildings 15, 16 and the old kitchen was completed in mid-February. This has enabled groundworks that include the construction of the underground water tank, drainage and foundations. All of the works are planned to be completed by the end of April 2014. The unprecedented wet and windy weather during January and February has badly penetrated the exposed external wall of the retained kitchen block and damaged some of the Jarvis works completed in the new kitchen. Kier made several unsuccessful attempts to make the wall temporarily waterproof and recent improvements in the weather has accelerated progress to that end. Kier will complete these works by mid April. The off-site construction of the new modules is in progress, with most of the modules started. A sample room should be ready for inspection at the end of March. All of the works needed to enable the Kier contract are complete with the exception of the Clinical Decisions Unit (CDU) works programmed for later this year. The consequential kitchen works, undertaken by Jarvis, will be delayed as the remedial works cannot be started until the outside wall is made waterproof by Kier. Handover of the kitchen is now likely to be in May 2014 (around 8 weeks late). This delay and damage will result in extra costs to the project. This is being assessed by the project team and its specialist advisor. The impact on the overall schedule due to the extreme weather in January and February conditions is being assessed by Kier, although at the present time there is no change to the current agreed work programme (version 19). Tenders for the CDU have been received from three contractors and are being assessed. Works are expected to start on site at the beginning of May 2014. A preferred contractor for the provision and installation of the new electrical cable has been identified and the works are programmed to be complete in accordance with the planned connection required to the new building. The business cases for the medical gases infrastructure work and additional generator are presented for consideration by the Board this month. Tenders are expected for the connection to the steam main by end of March, with work to be completed in June 2014, as per Kier’s programme.

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Shane DeGaris Chief Executive 17th March 2014

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26th March 2014

THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST REPORT TO: Trust Board REPORT FROM: Liz Weller, Head of Business Planning SPONSOR: Karl Munslow Ong, Chief Operating Officer DATE: 26th March 2014 SUBJECT: Shaping a Healthier Future – Progress update Trust Strategic Priority: This paper supports all of the Trust’s Strategic Priorities Summary: The purpose of this paper is to provide the Board with an update on implementation of the ‘Shaping a Healthier Future’ programme at the Trust. A draft outline business case (OBC), which now combines all the segments of maternity, non-elective services and backlog maintenance, was approved by the Trust Board in February for release into the SaHF assurance process. This assurance process includes an iteration period, currently forecast to run for two months from the date of receipt of all affected Trusts’ OBCs. During this iteration period, a process is being developed for engaging staff, public and patient representatives in the project development. The early stages will be as follows:

1 Master planning workshop to involve Governors, whose role is to represent public/patient interests

2 Briefing at the April CoG meeting 3 Public meetings for wider engagement

The Maternity Unit operates a regular liaison forum to benefit from patient input. This group will be asked to provide detailed support in project development. . Board Action Required: The Board is asked to review and note the attached briefing. Equality Impact Assessment: N/A – there is no positive or negative impact from this report

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Shaping a Healthier Future (SaHF) – Progress update

1. Introduction The Trust programme team has continued to prepare the business case for capital development which will help ‘future proof’ the Trust against the increasing demands upon its emergency and maternity services following implementation of the SaHF programme. High and significant backlog maintenance has also been included although the SaHF team acknowledge that this does not fully support the investment requirements for the Hillingdon site, and further consideration is being given to how this might be handled moving forward. The scheme is an integral part of the central North West London SaHF programme, which comprises a portfolio of projects for the delivery of strategic change throughout NWL, with an assurance process common to all of the projects forming the programme. THH will meet the requirements of this overall assurance process, but there may be an impact upon its project timing from other Trusts working to later timescales and requiring NHS TDA approvals. 2. Purpose of the OBC

The Decision Making Business Case (DMBC) for SaHF included a statement from the Trust: “We formally support the recommended option (option A) which, provided it is effectively implemented and backed by the requisite investment, has the potential to improve the quality of care, make good use of buildings and resources, and support research and education.” Since the approval of the DMBC, we have been working on the development of the OBC for maternity and neonatal services expansion, estates infrastructure improvements and emergency and critical care capacity increases at the Hillingdon Hospital site in support of the SaHF reconfiguration strategy for North West London. The main purpose of the OBC is to develop and appraise the options available and identify the preferred option to meet the Trust’s investment objectives. The case put forward in the OBC will later be developed in further detail in the Full Business Case (FBC) to demonstrate that the preferred option optimises value for money, is affordable, and is deliverable. 3. DMBC Capital assumptions and current figures The draft OBC includes the following capital costs: Current

£m DMBC

£M

A&E/Theatres/Recovery Expansion 3.5 2.2

Critical Care 1.4 0.8

Maternity – Preferred Option 20.7 10.5

Diagnostics – 2nd

MRI & CT 0 3.5

Backlog Maintenance 17.7 17.0

Total 43.3 34.0

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4. Conclusion

The draft OBC has been approved by the Board for release into the central assurance process, and was submitted on 12th March 2014. During the period of iteration further refinement will take place, with a final OBC for consideration and approval by the Trust Board in April.

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26th March 2014


REPORT TO: Trust Board REPORT FROM: Julie Wright, Director of Integrated Care REPORT SPONSORED BY: Karl Munslow Ong, Chief Operating Officer DATE: 26th March 2014 SUBJECT: North West London Whole Systems Integration Trust Strategic Priority: The report relates to all of the strategic priorities. Summary: Following ministerial prompts nationally, the pace and scale of integration has increased in the last 12 months. CCGs, local authorities, acute, community, primary care providers and third sector are currently working together on future integration models of care in Hillingdon. The integration agenda has gathered momentum as a consequence of several drivers; these include the Better Care Fund (BCF), Whole Systems Integration Pioneer plans and North West London Integrated Care pilots. This report outlines the drivers and progress with each one and provides an overview regarding North West London Seven Days Services programme project which is viewed as a key enabler. Board Action Required: The Board is asked to note developments and progress to date. Equality Impact Assessment: Not applicable at this stage

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Whole systems Integration: North West London Integrated Care

1. Background – Person Centred and Co-ordinated Care Many patients have complex care needs and currently services remain fragmented resulting in patients and carers finding it very difficult to access health and social care services to meet their needs. Services are often provided by different professionals, in a number of settings and across different providers without any help to navigate and at times resulting in poorer outcomes, with duplication and inefficiencies. Common features in the delivery of integrated care include risk stratification, multi-disciplinary team working and care planning. North West London (NWL) has had Integrated Care pilots running for a number of years and a Whole Systems Integrated Care Programme is viewed as the next stage in the journey to provide a seamless model of health and social care. The Whole Systems Vision is underpinned by 3 principles:

I. People will be empowered to direct their care and support and to receive care they need in their homes or local community

II. GPs will be at the centre of organising and coordinating peoples care

III. Our systems will enable and not hinder the provision of integrated care.

2. NWL Progress so far with Whole Systems Integration of Care (WSIC):

Hillingdon CCG – North 1 & 2 primary Care Network, submitted an expression of interest (EOI) supported in principle by CNWL, THHFT, GPs and Third sector. The Integrated Care EOI initially plans to support the elderly and frail population in Hillingdon. The integrated model is expected to include: • The GP as the professional, with overall responsibility for the patient including

approval of multi-disciplinary team (MDT) care plans. • MDTs, drawn from the Provider Network, to deliver care and the use of care

coordinators to support delivery of desired outcomes. The GP as the lead MDT professional drawing in whatever additional support (consultant, social care etc.) as is needed from the Provider Network to ensure care plan outcomes are delivered.

• A focus on supporting self-care and independence. • The use of capitated budgets and longer term contracts to increase incentives for

primary and secondary prevention. • Through the Better Care Fund, pooling commissioning budgets relating to

services commissioned for older people and exploring further pooling as part of this initiative.

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• Risk stratification. • Embedding ICP and its functions into the network. The EOI compliments the Better Care Fund submission with the London Borough of Hillingdon. Following a Whole Systems Integrated Care early adopters alignment workshop, Hillingdon CCG have re-submitted an expression of Interest to the North West London central team; with minor amendments and with the support of the above named providers - it is strongly anticipated that £50k will be allocated for project management support to help take the programme forward. Next Steps for NWL Whole Systems Integrated Care Pioneer

As outlined by the central team, following re-submission of EOIs (Expression of Interests) the most important next step will be to co-create the new model of care in detail and to consider the related implications by mid-April (noting that all EOI partnerships will need to work to the same mid-April timetable). The model of care will then drive further design options which will be worked through during the spring/summer. The NWL team advise local areas to start organising the relevant meetings to take the work forward. Hillingdon CCG’s Chair is currently arranging local meetings to clarify and work though the content of the EOI and to begin to develop a shared commissioner / provider vision on how Hillingdon might look in the future. Public Health will also join this group. Emerging early adopters will be offered support to do this, including a full-time project manager (for local selection), a fortnightly working session in each locality and general programme support in using the toolkit and pioneer help to unblock any challenges.

3. Better Care Fund Hillingdon Access to the Better Care fund (formerly known as the Integration Transformation fund) in 2015/16 will be dependent on a local 2-year plan for 2014/15 and 2015/16. The Hillingdon Health and Wellbeing Board set up a sub group to work up schemes, vision, scope changes and outcomes and to agree and sign off plans. THH is a member of this sub group and as such is actively involved. The plan has been written and, in principle, approved at the Health and Wellbeing Board and subsequently been submitted to NHS England on the 14th February. The plan is initially aimed at the elderly and the proposed schemes build on current existing early stages of integrated care, examples of which follow: • Developing role of rapid response • Improved and evolving urgent care pathway • Early supported discharge • Reablement Care • Emerging GP networks • End of life care including Co-ordinate My Care

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The table below details proposed BCF schemes

BCF Schemes Name of Scheme 2014/15 (initial rollout)

2015/16

Scheme 1 Jointed up tool for Health and Social Care Risk Stratification

√

Scheme 2 Proactive early identification of people with susceptibility to falls, dementia and social isolation

√ √

Scheme 3

Development of Shared Care Plans √ √

Scheme 4 Integrated Case Management and Care Co-ordination

√ √

Scheme 5 Realignment of Community Services to Networks

√

Scheme 6 Rapid Response and joined up Intermediate Care

√ √

Scheme 7 Early Supported Discharge √

√

Scheme 8 End of Life: Shared Care Plans and integrated response to people in terminal stage

√

Scheme 9 Care Homes Initiative √ √

Scheme 10 Seven Day Working Initiative √

Over time the implications for THH as an acute Trust with the implementation of the BCF proposals should mean fewer non elective admissions of older people and a shorter length of stay, this is also in alignment with Hillingdon’s out of hospital strategy and detailed plans in shaping a healthier future. Longer term, there may be an impact with the plans to follow a provider network model of care delivery in Hillingdon. 4. Integrated Care Innovation Projects The NWL ICP enters into a transition phase going into 2014/15 and dovetailing into the Whole Systems Integration programme within Hillingdon. Commissioners are currently putting a detailed service specification together which also sees some of the projects evolving into substantive models of care with a focus on outcomes monitoring. Some projects have been mainstreamed going forward, one example is the Falls Assisted Discharge Service, and Falls Outpatient Clinic. Both services are set to continue, the assisted discharge is being incorporated into THH early supported discharge model known as Home safe and the Falls outpatient clinic is being commissioned separately by the CCG. Full details of the ICP transition plans will be launched at a Hillingdon ICP sharing event where the success of 2013/14 will also be reviewed. A new initiative is planned which will see new Health and Social Care Coordinators working across three

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boroughs, they will be working with GP networks leads helping to implement and action care plans.

5. Seven Day Services

NWL was awarded ‘early adopter ‘status by the NHS England/NHSIQ Seven Day Services Improvement Programme. This means that NWL has a responsibility to progress the seven days services agenda at a scale and pace. Key messages: The key national drivers for Seven Day Services are, at least initially, ensuring that consistently high levels of quality and patient safety are achieved across all days of the week. There is already considerable work underway across NW London to progress the Seven Day Services agenda, for example: • SaHF Clinical Standards • Liaison Psychiatry in acute hospitals • GP Seven Day Access programme There are also already many working groups and meetings in place and there is a desire not to duplicate these. Therefore, the NW London Seven Day Services programme has two key roles:

I. To align and coordinate stakeholders across the health and care system of NW London to deliver seven day services through existing transformation programmes and commissioning approaches (it is anticipated that seven day services will become part of commissioning ‘business as usual’).

II. To provide a programme of direct support to Early Adopter provider organisations, starting with acute Trusts. The programme will report formally through the SaHF Board, and inform the Whole Systems Integrated Care Board.

High Level Approach – Main Steps • Confirm NW London seven day service standards across the whole system • Establish the baseline of seven day delivery across NW London (the national

self-assessment tool will be available on line for Trusts in early March) • Collectively agree the priorities and sequence for implementation • Develop a trajectory and action plan for each organisation • Design and implement a range of models to achieve standards (with support for

Early Adopters – as below) • Support, measure, learn, refresh. Delivery of seven day services will be central tenet of our service transformation agenda for 2014/15. Work is underway to evaluate how this will be amalgamated in to existing work programmes such as Improving Inpatient Care. The Trust is in the process of reviewing the seven day self-assessment tool and will be undertaking a baseline assessment at the end of March.

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6. Next steps for THHFT The Health and Social Care Act (2012) sets out an explicit focus on the importance of integrated care; as Monitor describes, integrated care is a new condition in the provider licence. This condition states that all licence holders shall not do anything that could reasonably be regarded as detrimental to enabling integrated care. Integrated Care is viewed by THHFT as an essential and vital way forward when planning and delivering health care services. The Trust is committed as part of its long term strategy to be seen as provider and system leader of integrated health and social care services. The completion of a Hillingdon Hospital integrated care programme/strategy will ensure that THH has patients experience and wellbeing aligned with integration of care and joined up services. THH also needs to: • Ensure THHFT attendance and contribution at the Whole Systems Integrated

Care local working groups and local GP led Expression of Interests.

• Continue to be actively involved in the detail and implementation of the Better Care Fund plan.

• Develop an Integrated Care Programme / Strategy in Quarter 4 of this financial year that will seek approval from THHFT Trust Board in Quarter 1 2014/15.

• Ensure the Integrated Care Programme will ultimately be a central part of the Trust Transformation Programme and will therefore fall within its overarching governance framework.

• Working with NWL Progress with a base line assessment of seven days services within the organisation and externally with social care and community based services. Undertake a gap analysis and progress with aligning seven day services where appropriate.

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26th March 2014

THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST REPORT TO: Trust Board REPORT FROM: Helen Kent, Organisational Development Advisor REPORT SPONSORED BY: Claire Gore, Director of People and Development DATE: 26th March 2014 SUBJECT: Staff Survey – 2013 Results and Action Plan _________________________________________________________________________ Trust Strategic Priority: • To create a patient centred organisation to deliver improvements in patient

experience and the quality of care we provide. • To deliver high quality care in the most efficient way. Summary: This paper provides an overview of the 2013 National Annual Staff Survey results for The Hillingdon Hospitals NHS Foundation Trust. The survey was developed via the National NHS Staff Survey Coordination Centre and was conducted on the Trust’s behalf by ‘Quality Health’ between November 2013 and February 2014. Board Action Required: The Board is asked to:

1. Note the results of the Staff Survey 2013. 2. Agree the recommendations set out in paragraph 4. 3. Agree the action plan set out in Appendix 3, which has been created following

analysis of the survey results. Equality Impact Assessment: No negative impact

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Staff Survey – 2013 Results and Action Plan 1. Introduction 1.1 Each year, NHS Trusts are provided with the results of the staff survey in order

to help them review and improve staff experience so that staff can provide better patient care. The data enables comparisons with previous years and the current national picture.

1.2 The results are used by the Care Quality Commission to monitor compliance

and essential standards of quality and safety. The survey also supports accountability of the Secretary of State for Health for the delivery of the NHS Constitution. The results were made available to Trusts in February 2014, and in March will be published on the Co-ordination Centre website.

1.3 In response to the Staff Survey 2012, an action plan was presented to the

Board resulting in work progressing throughout 2013 to address the concerns raised in the feedback. These include –

• In response to feedback on harassment, bullying and abuse, we – - Updated and promoted Dignity at Work policies via the Staff Bulletin and

Human Resources Consultants and Business Partners - Explored options for implementing a mediation service, still in progress - Continue to embed CARES throughout the Trust including specific events,

and implementing the Putting People First action plan (the progress for which is reported in the CARES update paper)

- Implemented an e-assessment module for conflict resolution

• In response to staff working additional hours and experiencing stress, we – - Created the Trust Health and Well-being strategy, promoting and making it

accessible on the intranet - Embedded the Management of Stress policy that promotes a risk-

assessment approach to stress management, conducting divisional and individuals’ assessments, which contributed to our recent achievement of level 2 in the NHSLA assessment of the Trust

- Continue to work with suppliers of our Employee Assistance programme - Developed health and well-being assessments for staff to self-refer onto; this

initiative will be ready for launch in the first quarter of 2014

• In response to the lack of job-relevant training, we – - Increased the number of staff receiving job-relevant training by 4% by

increasing the on-line training offer and targeting participants - Developed e-assessments for Equality and Diversity, and Information

Governance training

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- Scoped the possibility for supplying Statutory and Mandatory training more effectively, aligning to the national core skills framework enabling skills transfer across the NHS

1.4 In January 2009, the NHS Constitution outlined the principles and values of the

NHS in England including four pledges that set out what staff should expect from NHS employers. They are part of the commitment of the NHS to provide high-quality working environments for staff – Pledge 1: To provide all staff with clear roles and responsibilities and rewarding jobs for teams and individuals that make a difference to patients, their families and carers, and to communities.

Pledge 2: To provide all staff with personal development plans, access to appropriate training for their jobs and the support of line management to succeed. Pledge 3: To provide support and opportunities for staff to maintain their health, wellbeing and safety Pledge 4: To engage staff in decisions that affect them and the services they provide, individually, through representative organisations and through local partnership working arrangements. All staff will be empowered to put forward ways to deliver better and safer services for patients and their families.

1.4 The NHS staff survey is structured around the four pledges to staff in the NHS Constitution, with additional themes of staff satisfaction and equality and diversity. The Trust also requested further questions in the areas of Leadership, Patient Experience and CARES, the Trust’s values.

2. Outcomes from the 2013 Survey 2.1 A breakdown of the survey and comparisons with previous year at Appendix 1

and are compared with results of the 2012 survey results. The additional local questions requested by the Trust are at Appendix 2.

2.2 The response rate for the Staff Survey 2013 nationally was 49% for all Trusts. The response rate for the Hillingdon Hospitals NHS Foundation Trust was 45% for 2013. For 2012 the Trust’s response was 44% for the original sample, and 45% for the extended sample.

2.3 The survey reports a score from 1 to 5 for staff engagement, with 1 being a poorly engaged and 5 being highly engaged workforce. The Trust’s score for engagement is 3.77, above the national average of 3.73 and an improvement on our 2012 score of 3.75.

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2.4 Scores for staff motivation, and whether staff would recommend the Trust to friends and family as a place to work or receive treatment, which also demonstrate staff engagement, show an improvement on 2012 and is above the national average.

2.5 However, scores for job satisfaction, and the extent to which staff are able to

make suggestions contributing to improvements at work, are both below the national average for acute Trusts. In addition, job satisfaction scores are worse than our score in 2012.

2.6 The Trust is scored in the top 20% of Trust scores in 3 areas for 2013 –

(i) Staff agreeing their training helped them deliver better patient service (ii) Staff having an appraisal in the last 12 months; declined from 2012 (iii) Staff often or always looking forward to work, improved from 2012

2.7 The Trust is also scored at the threshold of the top 20% of Trusts in 4 areas for 2013, all of which demonstrate an improvement on our 2012 scores –

(i) Staff able to implement improvements happen in their areas of work (ii) Staff are satisfied with the quality of care they give (iii) Staff agree their role makes a difference to patients and service users (iv) Staff who have not experienced violence from the public

2.8 The Trust’s 5 most improved scores are –

(i) Staff receiving equality and diversity training (ii) Staff not working additional unpaid hours (iii) Staff agree training helped deliver better patient and service user service (iv) Staff agree that patient and service user care is the Trust’s top priority (v) In the last month staff had not witnessed potentially harmful errors or near

misses 2.9 There are 10 areas of concern, included in the action plan at Appendix 3, where

scores are at or below the threshold for the bottom 20% of Trust scores. These are –

(i) Receipt of health and safety training in the last 12 months (though improved, and is only required once every 3 years)

(ii) Receipt of infection control training in the last 12 months (also only required once every 3 years)

(iii) Staff satisfied with the level of responsibility given (iv) Staff agreed the Trust encourages reporting of potentially harmful errors (v) Staff know how to report errors or malpractice or fraud (vi) Staff reporting physical violence (vii) Staff perception of fairness with respect to career progression (viii) Staff experiencing discrimination from the public at work (ix) Staff experiencing discrimination from colleagues at work

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(x) Provision of clear answers to important questions to patients.

2.10 Performance has improved since the 2012 survey with respect to items 2.9 i, ii, vi, vii and ix. Performance has deteriorated since the 2012 survey with respect to items 2.9 iii, iv, v, viii and ix.

2.11 Key messages from additional questions asked in 2013 are – Patient Experience The Trust chose to include these questions in the survey, and they now form part of the core questionnaire for all Trusts. Scores fall into 3 main categories – (i) Better than the Trust score for 2012 and better than the 2013 national score

• Perception of public confidence in the Trust’s nurses • Perception of public confidence in the Trust’s doctors • Perception of public confidence in the Trust’s allied health professionals • Perception that patients receive enough emotional support • Perception that patient safety is a Trust priority • Staff believe there are enough staff to meet patient needs • Perception that allied health professionals provide clear answers to

patient’s questions

(ii) Better than the Trust score for 2012, worse than the 2013 national score

• Perception that patients are involved in decisions about their care • Perception that patients are treated with dignity and respect • Perception that patients are provided with enough privacy during

treatment • Concern that patients have access to clean toilets and bathrooms • Perception that nurses provide clear answers to patient’s questions • Perception that doctors provide clear answers to patient’s questions • Concern that patients receive consistent information about their

treatment

(iii) Worse than both the Trust 2012 scores and the national 2013 score

• Concern about patients being given enough information about their treatment

Leadership and Management There is an improvement in the Trust’s 2013 scores, both in relation to our 2012 scores and the 2013 national scores, in staff perception that the organisation has a clear vision, that they feel they are part of its future, have the capability – and are encouraged by their managers – to be a leader. There is a slight

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improvement on 2012 scores in staff perception of the importance of being a role model and motivating others. The 2013 Trust scores show no improvement since 2012, and are below or equal to national 2013 scores in opportunities professional growth, access to learning and development materials when required, and the importance of being accountable for the decisions respondents make.

CARES Values There is an 8% increase since 2012 in the number of people aware of CARES values, and an increase in the cascade of information from managers to staff. There is a notable improvement understanding that the CARES values will improve the way people work, make a difference to patient care and make Hillingdon Hospitals good places to work.

2.12 Further Directorate and Staff Groups analysis is being undertaken to be shared

with Divisional leads, to enable targeted local action should any be required, including celebrating of notably high performance, and communicating key messages about improvements to be made and best practice.

3. Conclusions 3.1 The pace of increase in response rate is slowing. Work must continue to

improve the rate of return of the survey including the communicating of action taken since the last survey.

3.2 There are some notably high scores around valuing the purpose of training in the delivery of high quality patient care, staff enjoyment of work, and completion of appraisals, which place the organisation in, or at the threshold of, the top 20% of acute trusts.

3.3 The red indicators relate largely, directly or indirectly, to patient care and safety,

and staff safety. These include training in health and safety and infection control (which are only required once every 3 years), encouragement to report errors, knowledge of how to report malpractice, reporting of physical violence and nurses providing clear answers to patient questions.

3.4 Other red indicators relate to staff experience including satisfaction with level of

responsibility, fairness in career progression, experiencing discrimination from staff and the public. However, it should be noted that there are more findings of improved staff experience than there are of deteriorating experience.

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4. Recommendations 4.1 Publishing the survey results for 2013 is recommended throughout the Trust in

various media to maximise accessibility to the information. In order to demonstrate that the Trust listens and acts on staff feedback, actions taken in relation to the results will be publicised as they occur throughout the year.

4.2 CARES Ambassadors are taking a keen interest in the results and will be key to help spread and cascade the results and provide information on the Trust’s plans.

4.3 An action plan has been drafted (Appendix 3) which is specifically focussed in

key priority areas to ensure actions are achievable and not over-ambitious. This follows the recommendations of Quality Health. To ensure progress is monitored, this work reports into the Experience and Engagement Group. Divisions will also for the first time have their own individual results and the Business Partners will work with them to develop their own action plans.

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Appendix 1 Summary Staff Survey Results 2013 and Comparison Results with 2012 Survey The Department of Health 2013 National NHS Staff Survey Results report for the Trust showed that 2576 people were sent the questionnaire; 55 were returned without being completed, 165 were excluded as ineligible and 1405 others not returned. The 1171 usable responses from a final sample of 2576 is a response rate of 45%; a 1% increase in the 2012 response rate of the 2012 original sample, and equal to the response rate for the additional 2012 sample. The following tables and charts provide a summary of the key trends and scores, both the best and areas for concern. TABLE 1: Overall Indicator of Staff Engagement for Hillingdon Hospitals NHS Trust

Ranking comparison with other Acute Trusts

Change since 2012 Survey

Overall staff engagement (3.77) Above (better than)

average (3.73) Small increase (0.01)

(better than 2012)

Key Finding (KF)22 Staff ability to contribute to improvements at work Below (worse than) average No change

KF23 Staff job satisfaction Below (worse than) average Decrease (worse than) 2012

KF24 Staff recommendation of the Trust as a place to work or receive treatment

Above (better than) average

Increase (better than 2012)

KF25 Staff motivation at work Above (better than)

average Increase

(better than 2012) TABLE 2: The Trust’s Top 3 Ranking Scores (In the top 20% of Trusts)

Key Finding Acute Trusts Rank Comparison

Change since 2012 Comments

Q2a Staff agreed training helped them deliver better patient or service user experience

In the top 20% 5% (better) increase

The Trust achieved 68% compared with a national average of 62% and a top 20% threshold of 67%

Q3a Staff had appraisal in the last 12 months

In the top 20% 2% (worse) decrease


Q5a Staff often or always look forward to work

In the top 20% 3% (better) increase


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TABLE 3: The Trust’s 4 Other High Ranking Scores (At threshold of top 20% of Trusts)



Q7d Staff able to make improvements happen in their areas of work

At the threshold of the top 20%

3% (better) increase

The Trust achieved 58% compared with a national average of 53%

Q9a Staff are satisfied with the quality of care they give




Q9b Staff agree that their role makes a difference to patients and service users




Q20a In last 12 months, staff have not experienced violence from the public




TABLE 4: The Trust’s Bottom 10 Ranking Scores (Below or at threshold of bottom 20%)



Q1a Received health and safety training in last 12m (Required every 36m)

Below bottom 20% threshold

4% increase (better)

The trust achieved 68% compared with a national average of 77% and a bottom 20% threshold of 71%

Q1d Received infection control training in last 12m (Required every 36m)



The trust achieved 69% compared with a national average of 80% and a bottom 20% threshold of 74%

Q8e Staff satisfied with level of responsibility given


1% decrease (worse)

The Trust achieved 72% compared with a national average of 74% and a bottom 20% threshold of 73%

Q18b Agreed Trust encourages staff to report errors


2% decrease (worse)


Q19a Staff know how to report malpractice concerns

At the threshold of the bottom 20%

2% decrease (worse)


Q20c Staff reporting physical violence at work


9% (better) decrease


Q22 The Trust is fair with regards to career progression




Q 23a Staff have experienced discrimination from the public in last 12m


1% increase (worse)


Q23b Staff have experienced discrimination from colleagues in last 12m


2% increase (worse)


Q37a Patients get clear answers to important questions from nurses

At the threshold of the bottom 20%



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TABLE 5: Key Findings of improved staff experience

Key Finding 2012 Survey

2013 Survey Improvement

KF1 Percentage of staff feeling satisfied with the quality of work and patient care they are able to deliver 79% 83% 4%

KF2 Percentage of staff agree that their roles makes a difference to patients 90% 91% 1%

KF3 Score for work pressure felt by staff 3.01 2.96 0.005

KF4 Score for effective team working 3.67 3.71 0.04

KF5 Percentage of staff working additional hours 74% 66% 8%

KF11 Percentage of staff experiencing work-related stress in the last 12 months 37% 36% 1%

KF16 Percentage of staff experiencing physical violence from patients, relatives or the public in the last 12 months. 16% 13% 3%

KF17 Percentage of staff experiencing physical violence from staff in the last 12 months 4% 3% 1%

KF18 Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12m 33% 29% 4%

KF19 Percentage of staff experiencing harassment, bullying or abuse from staff in the last 12 months 26% 24% 2%

KF8 Percentage of staff having well-structured appraisals in the last 21 months 46% 47% 1%

TABLE 6: Key Finding where staff experience has deteriorated

Key Finding 2012 Survey

2013 Survey Decline

KF9 Score for support from immediate managers 3.71 3.61 0.1

KF15 Score for fairness and effectiveness of procedures for reporting errors, near misses and incidents 3.49 3.47 0.02

KF27 Percentage of staff who believe that the Trust provides equal opportunities for career progression and promotion 85% 81% 4%

KF28 Percentage of staff experiencing discrimination at work in the last 12 months 14% 15% 1%

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TABLE 7: Summary of all Key Findings for NHS Staff Survey 2013 Results

Key Finding (Scores for groups of questions aggregated to themes)

Change since 2012

Acute Trusts Rank Comparison

Trust Score 2013

STAFF PLEDGE 1 – To provide staff with clear roles, responsibilities and rewarding jobs 1 % staff satisfied with quality of work and patient care they deliver Better by 4% Above (Better than 78%) 83% 2 % agreeing their role makes a difference to patients Better by 1% Above (Better than 90%) 91% 3 Work pressure felt by staff Better by 0.05 Below (Better than 3.06) 2.96 4 Effective team working Better by 0.03 Below (Worse than 3.74) 3.71 5 % working extra hours Better by 8% Below (Better than 70%) 66%

STAFF PLEDGE 2 – To provide staff with personal development, access to appropriate training for their jobs, and line-management support to succeed 6 % receiving job-relevant training or development in last 12 mnths Better by 4% Equal to average 81% 7 % appraised in last 12 months Worse by 1% Above (Better than 84%) 92% 8 % having well-structured appraisals in last 12 months Better by 1% Above (Better than 38%) 47% 9 Support from immediate managers Worse by 0.10 Below (Worse than 3.64) 3.61

STAFF PLEDGE 3 – To provide support and opportunities for staff to maintain their health, well-being and safety Occupational Health and Safety 10 % receiving health and safety training in last 12 months Better by 3% Below (Worse than 76%) 67% 11 % suffering work-related stress in last 12 months Better by 1% Below (Better than 37%) 36% Infection Control and Hygiene 12 % saying hand washing materials are always available Better by 2% Below (Worse than 59%) 56% Errors and incidents 13 % witnessing potentially harmful errors, near misses, incidents in last mnth Better by 2% Below (Better than 33%) 27% 14 % reporting errors, near misses or incidents witnessed in the last month Worse by 5% Equal to average 90% 15 Fairness and effectiveness of incident reporting procedures Worse by 0.02 Below (Worse than 3.51) 3.47 Violence and Harassment 16 % experiencing physical violence from patients/relatives/public in last 12m Better by 3% Below (Better than 15%) 13% 17 % experiencing physical violence from staff in last 12 months Better by 1% Equal to average 3% 18 % experiencing harassment/bullying/abuse from patients/relatives/public in last 12m Better by 4% Equal to average 29% 19 % experiencing harassment, bullying or abuse from staff in last 12 months Better by 2% Equal to average 24% Health and Well-Being 20 % feeling pressure in last 3 months to attend work when feeling unwell Equal to 2012 Above (Worse than 28%) 30% STAFF PLEDGE 4 – To engage staff in decisions that affect them, the services they provide and empower them to put forward ways to deliver better and safer services 21 % reporting good communication between senior management and staff Worse by 1% Above (Better than 29%) 30% 22 % able to contribute towards improvements at work Equal to 2012 Below (Worse than 68%) 67% ADDITIONAL THEME – Staff Satisfaction 23 Job satisfaction Better by 0.03 Below (Worse than 3.60) 3.59 24 Staff recommendation of Trust as a place to work or receive treatment Better by 0.04 Above (Better than 3.66) 3.70 25 Staff motivation at work Better by 0.06 Above (Better than 3.86) 3.95 ADDITIONAL THEME – Equality and Diversity 26 % having equality and diversity training in last 12 months Better by 6% Below (Worse than 59%) 56% 27 % believing Trust provides equal opportunities for career progression or promotion Worse by 4% Below (Worse than 88%) 81% 28 % experiencing discrimination at work in last 12 months Worse by 1% Above (Worse than 11%) 15%

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TABLE 8: Charts Summarising Historic Trends (Note that the vertical scales differ between Key Findings, and should only be used for year on year comparisons for that Key Finding, and not for comparison between Key Findings)

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Appendix 2 Additional Questions Scores for the Trust 2013 (Patient Experience, Leadership, CARES Values)

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Appendix 3 2014 ACTION PLAN

Survey Outcome Action Required Trust Strategic Priorities Lead Measures of Success Timeframe Reporting Method

1. Any outcomes showing differences in group scores

Further analysis of the results to identify and address any significant directorate or staff group differences

To deliver high-quality care in the most efficient way. Maximise staff contribution to transforming the way we deliver our services.

P&D/ ADOs

• Completion of analysis • Info shared with HRBPs • Divisional action plans

developed with HRBPs

31-Mar-14 30-Apr-14 30-Apr-14

2. Patients getting clear answers to questions from Nurses

• Monitor trend from the patient surveys to ensure the 3% improvement from last year continues to progress.

• Review action required at end of first quarter with trend information.

• Develop action plan if trend reverses.

To create a patient centred organisation to deliver improvements in patient experience and the quality of care we provide. Improve patient experience.

Bev Hall

• Confirmation of trend at the end of 1st quarter

• Action plan developed (if trend reverses)

• Improved scores in the 2014 Staff Survey

30-Jun-14 (first

review) and ongoing

3. Staff experiencing violence from members of the public, and harassment, bullying and abuse from the public and staff

• Monitor trend to ensure the 9% improvement from last year continues

• Consider seeking advice from the enhanced network of NHS Protect’s Area Security Management Specialists

• Step-up training in conflict prevention • Note NHS Protect’s new guidance “Meeting

needs and reducing distress – Guidance on the prevention and management of clinically related challenging behaviour in NHS settings”

• Encourage reporting of violence • Set up CARES Dignity at Work group to have

a particular focus on issues arising • Engage managers in Ambassadors’ work


P&D/ Security

• Confirmation of trend at the end of 1st quarter

• Action plan developed (if trend reverses)

• Improved scores in the 2014 Staff Survey

30-Jun-14 (first

review) and ongoing

4. Reporting errors and knowledge of reporting process

• Communication campaign (e.g. staff bulletin, intranet front page, management briefs)

• Training targeted to workgroups (see 1.)


P&D/ Jackie Walker

Sue Manthorpe

• Increased response in 2014 staff survey to the question on those knowing procedure

• Reduction in the number of reports of errors

February 2015

5. Appraisal quality, review career paths, progression, responsibility, discrimination

• Review analysis of divisional differences to determine if action is required locally or corporately

• Set up a PDR Working group to review and enhance the TM/PDR processes with a view to improving the quality and content including the introduction of performance related pay progression


P&D

• Identification of local needs • Simplified PDR process for

2014 • Improved scores in the 2014

Staff Survey

TBC

ITEM 11



REPORT TO: Trust Board REPORT FROM: Tally Kandola, Head of Organisational

Development REPORT SPONSORED BY: Claire Gore, Director of People and Development DATE: 26th March 2014 SUBJECT: Embedding of the Trust Core Values (CARES) Trust Strategic Priority: • To create a patient centred organisation to deliver improvements in patient

experience and the quality of care we provide. • To deliver high quality care in the most efficient way Summary: This report provides an update on progress in embedding the Trust’s values and how these continue to be incorporated into key Trust processes/initiatives. Board Action Required: The Board is asked to: 1. Note the report and make comment 2. Agree the proposed priorities for 2014/15

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Embedding of the Trust Core Values (CARES) 1. Introduction The Trust values were reviewed in November 2010 when it became apparent that there was the need to refresh and build on the existing values. In particular, a gap was identified around the underpinning behaviours expected of staff. Clearly defined behaviours are needed to provide staff with a framework and minimum standard of behaviour that is expected across the Trust. 2. Putting People First The CARES culture and values behavioural framework was developed in conjunction with staff and other key stakeholders and launched in April 2012. It was recognised that if they were to have a real demonstrable impact they needed to be embedded across the Trust so that they are at the heart of everything we do. A number of initiatives were identified in conjunction with staff from across the Trust and were delivered through a number of work streams as follows:

• Patient and Staff Engagement • Retention and Recruitment • Performance and Development • Reward and Recognition • Patient Experience Programme

2.1 Progress Some significant progress has been made against each of the work streams listed above, these are summarised as follows: 2.1.1 Patient and Staff Engagement

• Delivery of the Year One action plan of the Experience and Engagement Strategy - achieved apart from development of local staff questionnaire due to the impending FFT test for staff.

• New starters are informed of the CARES values early on as part of their corporate induction

• Updates regularly given to staff and PIP via a number of different methods of communication and engagement

2.2.1 Retention and Recruitment

• Standardised CARES questions have been developed for use during selection processes

• Student nurses are selected using values based recruitment • A review of the exit interview process has taken place to improve the

capture of intelligence for use as learning opportunities to make improvements to staff experience

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2.3.1 Performance and Development • The People and Organisational Development and Leadership strategies

are both underpinned by the CARES values • CARES has been incorporated into the Leadership 100 programme in the

Managing Self and People modules • The CARES behavioural rating scale has been incorporated into the

PDR/TM paperwork and was used for the 2013 cycle with positive feedback from staff about being able to discuss behaviour and attitude in an open manner, focusing people on the importance and relevance of the behaviours to their role. It is proposed that the new performance appraisal will include a rating for behaviours and form part of the decision as to whether an increment should be awarded (or in some cases withdrawn).

2.4.1 Reward and Recognition

• The staff awards have been reviewed in line with the CARES values and have been re-launched to reward individuals who are exemplars of CARES. The profile of the awards has been raised and the ceremony will take place at an off-site location with Board members present. This year we will also be formally recognising long service at the award ceremony for the first time.

2.5.1 Patient Experience Programme • The bespoke Customer Care training programme was developed in

conjunction with Interact (external provider) using patient complaints, feedback from patients/staff and incidents to ensure that the scenarios used were taken from local issues that staff could relate to and were pertinent to the Trust.

• The training rollout commenced in June 2013 with 31% of staff being trained to date. The training was paused during the winter period but will commence again in April 2014.

2.6 CARES Ambassadors

A major part of raising awareness and embedding CARES across the Trust was to have members of staff who were real ambassadors and exemplars of CARES. It would be fair to say that at the beginning the role and responsibilities of the Ambassadors were not clearly defined but they have worked with the OD team to develop and identify their role within the Trust. There are currently 29 Ambassadors made up from a range of disciplines across the Trust and include consultants, domestics, administration and clerical, midwifery and therapy staff.

The Ambassadors meet on a monthly basis to network and share ideas about how they embed the CARES values. So far the Ambassadors have raised awareness through: 2.6.1 Promoting CARES at own team meetings, attending other departmental team

meetings and audit days to remind people about the importance of CARES e.g. Introducing a ‘Hands that care board’ within Alexandra ward which consists of ‘A pat on the head’ for things that the team or individuals have

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done well or ‘A hand’s up’ where things could have been better. This encourages open, no blame team work and the whole team taking responsibility for making changes.

2.6.2 Role modelling the behaviours. 2.6.3 Encouraging teams to have a positive attitude and supporting them to take

responsibility to look for solutions rather than ‘just letting off steam’ about issues.

2.6.4 In response to the patient survey identifying that we are not reaching all patients one of the Ambassadors has been talking to patients and their relatives about CARES and our FT status and how it impacts on their healthcare so it is more easy to understand than the leaflets that are in English.

2.6.5 Leading by example and taking responsibility for talking to patients even if a problem cannot be resolved, listening to their concerns makes them feel that we care.

2.6.6 The introduction of the CARES Communications Board to promote the work the Ambassadors are doing and to share CARES related information with staff and patients.

2.6.7 Promoting a 60 second questions initiative, by approaching staff and asking questions in relation to CARES to check understanding.

2.6.8 Co-ordination of the ‘Show you CARES day’ giving staff the opportunity to recognise the work of individuals or teams.

2.6.9 Launch of the Dignity at Work group looking at particular issues in relation to harassment and bullying.

The Ambassadors have identified a number of projects that they will be working on to continue to promote CARES in a variety of ways, as these gain momentum further reports on progress will be provided. 2.7 CARES Ambassadors Development Programme

It was recognised that the Ambassadors needed to be supported in their roles. A two day development programme was designed to equip the Ambassadors with the skills to carry out their roles more effectively, they focussed on:

• What it takes to be an Ambassador • Giving feedback where behaviours are demonstrated or not demonstrated as

per the CARES behavioural framework • Promoting CARES at local level creatively.

Feedback from the Ambassadors about both days was positive. 3. Impact to date

Whilst it is recognised that there is still work to be done to embed our values and that communication and attitude still features in our top ten reasons for complaints there has been some significant impact which is has been demonstrated through the following:

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3.1 Comparisons of the 2012 and 2013 Staff Survey There is an 8% increase on the 2012 survey in the number of people aware of CARES values. There is a notable improvement of staff understanding that the CARES values will improve the way people work, make a difference to patient care and make Hillingdon Hospitals a good place to work (Appendix 1). The Overall engagement score has increased to 3.77, above the national average of 3.73 and an improvement on our 2012 score of 3.75. In relation to the survey questions that make up this score the following improvements have been made:

• An increase in the number of staff stating that they would recommend the Trust as a place to work or receive (3.66 to 3.70)

• Staff motivation at work has improved (3.89 to 3.95) • An increase of 19% for staff receiving training on how to deliver a good

patient/service user experience (67% - national average is 53%) • A 5% increase in staff feeling that training has helped them deliver better

patient care (69% compared to the national average of 62%).

3.2 Complaints The table at Appendix 2 indicates that there was a significant increase in complaints during the latter part of 2012 and early part of 2013; this could be contributed to the publicity surrounding the Francis, Cavendish and Keogh Reports, indeed many complaints from both staff and patients/carers cite our CARES values. However, there has been a decline in the last three quarters of 2013/14 in the number of complaints received in relation to staff attitude, communication/information to patients and patient discrimination. This improvement could be attributed to the customer care training which began at the end of Q1. Whilst not yet complete the January – February 2014 data indicates that we could have fewer complaints in Q4 of 2013/14. 3.3 Patient experience results A survey of inpatients is part of the annual mandatory survey programme for acute Trusts. Hillingdon commissioned The Picker Institute to undertake the survey. The Care Quality Commission (CQC) will use these results when publishing the national survey of inpatients in late spring. The CQC will standardise results taking into account the age, gender and route of admission. In 2012 THH had 43 questions with problem scores that were significantly worse than the average score of all Picker Trusts. In 2013 THH had 16 questions with problem scores that are significantly worse than the average score of all Picker Trusts, although the Trust results had improved in 13 of these questions, stayed static in one question and deteriorated in two questions. The deterioration was noted in questions related to privacy in A&E and having enough time to discuss operations or procedures with a Consultant.

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There was one question with a problem score that is significantly better than other trusts. This question is related to same sex accommodation and sharing bathrooms with members of the opposite sex. Historical comparison 2013 to 2012: The table below provides a summary of the survey results, comparing the movement in questions between 2012 and 2013. Movement Number of questions Improvement 68 Static 7 Deterioration 10 Total 85

The deterioration was noted in questions related to:

• Privacy in A&E

• 3 questions related to planned admissions

• Being bothered by other patients’ visitors

• 3 questions related to surgery

• Not being given notice about discharge date

• Not given written/printed information about medication at discharge

Significant Improvements:

Significant improvements were demonstrated in 5 questions

• Patients reporting feeling threatened by visitors or other patients

• Being able to find a member of staff to discuss worries or concerns with

• Overall rating of experience

• Receiving information about how to complain

• Overall, wanting to complain about care received

Questions two and three are used by the CQC. They were a risk rated in the recent CQC Intelligent Monitoring Report ( based on last year’s survey) so this is a positive result. There were no significant deteriorations reported.

3.4 National recognition

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The Trust was shortlisted for two national awards in February 2014. These were the HR Distinction Awards in the category of “Distinction in Employee Engagement” and the Patient Experience Network National Awards (PENNA), in the “Setting the Stage - Strengthening the Foundation” category for the work we have done with CARES. We received runners up Award for the Patient Experience Network Awards. Although THH did not win at the HR Distinction Awards, being shortlisted was an achievement in itself. This recognition provides encouragement that we are going in the right direction with embedding our CARES values to assist with the delivery of our vision “To put compassionate care, safety and quality at the heart of everything we do”.

4. Priorities for 2014/15

The action plan at Appendix 3 sets out the priorities for CARES in the coming year. 5. Conclusions

4.1 There has been some good progress with the original work streams in embedding CARES into processes and initiatives but it is recognised that further work needs to be done to keep the momentum and key messages alive.

4.2 The CARES Ambassadors role is proving to be a valuable resource in raising

awareness through a ‘snow balling’ effect with their persistent messages. The projects that the Ambassadors themselves have identified will have a further impact on embedding our values and reinforcing them. Additional work to support the role will continue.

4.3 The customer care training appears to be having a positive impact on staff

and patient care. The target was not achieved due to winter pressures but a significant number of staff were trained. Some more workshops need to be organised to ensure that all staff are trained.

4.4 Since the launch of CARES we have seen a year on year improvement in staff

engagement. 4.5 The work to review, launch and embed our values is also getting recognition

externally and it is being recognised as good practice to be shared and we will continue to raise Hillingdon’s profile in this way.

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Appendix 1

Staff Survey CARES questions comparison 2012 - 2013

LOCAL QUESTIONS Total 2012 Total 2013 L01a. I understand what CARES is. 8% Increase Strongly disagree 2% 1% Disagree 3% 2% Neither agree nor disagree 10% 6% Agree 58% 56% Strongly agree 26% 36% Missing L01b. My manager has spoken to me about CARES. 5% Increase Strongly disagree 7% 4% Disagree 14% 11% Neither agree nor disagree 13% 14% Agree 47% 48% Strongly agree 19% 23% Missing L01c. CARES will make Hillingdon Hospital a good place to work. 11% Increase Strongly disagree 5% 4% Disagree 8% 7% Neither agree nor disagree 38% 28% Agree 34% 41% Strongly agree 16% 20% Missing L01d. CARES will make a difference to patient care. 14% Increase Strongly disagree 4% 3% Disagree 8% 7% Neither agree nor disagree 36% 26% Agree 36% 43% Strongly agree 15% 22% Missing L01e. CARES will make a difference to the way I do my job. 13% Increase Strongly disagree 7% 6% Disagree 13% 9% Neither agree nor disagree 36% 28% Agree 30% 37% Strongly agree 14% 20% Missing

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Appendix 2

Chart 1 - ** Each complaint can have multiple subjects of complaint

0

20

40

60

80

100

120

11/12 Q1 11/12 Q2 11/12 Q3 11/12 Q4 12/13 Q1 12/13 Q2 12/13 Q3 12/13 Q4 13/14 Q1 13/14 Q2 13/14 Q3 Jan - Feb2014

Complaint Subjects - Communication and Attitude

Attitude

Communication

Attitude and Communication

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Appendix 3 Action Required

Trust Strategic Priorities

Responsible Person

Measures of Success Time Frame Reporting Mechanisms

Implement the Staff FFT questions to gain more frequent data on staff engagement levels

To create a patient centred organisation to deliver improvements in patient experience and the quality of care we provide

Head of OD Implementation of the FFT and ongoing improvements of scores

30/4/14 EEG

Explore options for implementing Values Based Recruitment

To deliver high quality care in the most efficient way

Head of OD Options paper available for discussion

31/5/14 To be determined

Restart the Customer Care Training


OD Advisor 75% of staff trained 31.3.15 EEG

Build relationships with managers and CARES Ambassadors to improve engagement with CARES


Ambassadors Forum

Ambassadors able to approach managers with issues of concern in relation to the CARES values

30/4/14 and maintain on an on-going basis

EEG

10

Incorporate the CARES behaviours as a weighted element of performance related pay progression


Director of People

Delivery of the reviewed PDR process incorporating performance related pay progression

2015/16 full implementation

EEG

Co-ordinate and host the Staff Awards event to thank individuals/teams that have nominated for their hard work


Head of OD Successful delivery of the event

25/4/14 EEG

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26th March 2014

THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST REPORT TO: Trust Board REPORT FROM: Helen Hardy, Cancer and Nursing Services

Manager REPORT SPONSORED BY: Karl Munslow Ong, Chief Operating Officer. DATE: 26th March 2014 SUBJECT: London Cancer Alliance Membership

Arrangements Trust Strategic Priority: • To create a patient centred organisation to deliver improvements in patient

experience and the quality of care we provide. Summary: The London Cancer Alliance (LCA) is the integrated cancer system and strategic clinical network for cancer for West and South London. In December 2013 the LCA consulted its members on the future membership arrangements and moving to a subscription-based members organisation. The consultation concerned three areas; the introduction of a new value added service model provided to members in return for moving to a member subscription service; a financial model; and governance arrangements. A simple majority of views expressed by LCA members would be applied in determining a way forward. The proposal for a subscription is set in the context of bridging the gap between the funding the LCA receives from its principle investors (i.e. Academic Health Science Networks) and LCA’s operational budget requirements. Board Action Required: The Board is asked to:

1

1. Note the outcome of the consultation describing the benefits that would arise out of the membership changes proposed and implications of the subscription charges.

2. Continue to support the Trust’s membership of the LCA in light of these changes.

Equality Impact Assessment: There is no positive or negative impact arising from this report.

2

London Cancer Alliance Further Membership Arrangements

1. Background The London Cancer Alliance (LCA) is the integrated cancer system and strategic clinical network for cancer for West and South London. The LCA’s principal aim is to transform the organisation and delivery of cancer services across the Alliance to ensure they are world-class. In December 2013 the LCA consulted its members on the future membership arrangements which included a proposed move to a subscription-based members organisation. The consultation concerned three areas; the introduction of a new value added service model provided to members in return for moving to a member subscription service, a financial model and governance arrangements. A simple majority of views expressed by LCA members would be applied in determining a way forward. It is worth noting that the proposal for a subscription is set in the context of bridging the gap between the funding the LCA receives from its principle investors (i.e. Academic Health Science Networks (AHSNs)) and LCA’s operational budget requirements. This paper summarises the Trust’s response to consultation and anticipated benefits and the outcome of the consultation outlining the changes and implications of the subscription charge. 2. Trust response to the consultation. The consultation is set out in three parts, seven point value added proposition, finance and governance arrangements. 2.1 Seven point value added proposition This proposition takes the form of introducing a new service delivery model for the LCA and covers 7 key areas:

• Clinical engagement and delivery • Quality assurance, performance and informatics • Intensive support • Action planning • Workforce development and support • Research and development • Representing the membership.

3

The Trust has anticipated a number of benefits this model would deliver, most obviously developing and maintaining relationships with other stakeholders. A number of clinicians from the Trust are part of LCA clinical working groups and are involved in discussions about best practice commissioning pathways and service redesign. The LCA provides a forum where consensus about the management of clinical pathways can be achieved which, for a cancer unit working alone, could be challenging and risky. Furthermore, wider engagement is welcome as it fits with the Trust’s current review of some cancer services - for example scoping the potential of providing chemotherapy for solid tumors. Secondly the LCA’s quality assurance framework provides valuable statistics about the performance of different tumor groups which again is used to target areas of good practice and introduce remedial actions. The Trust consistently performs at a high level against these metrics some of which are also available to patients and may well be used to influence their choice about providers. Lastly the LCA is offering support from its core staff and professional expertise across the membership to Trusts facing significant challenges with their services or pathways. Again the Trust anticipates this support would add an enhanced calibre of knowledge in some of our newer pathways such as carcinoma of the unknown primary. 2.2 Finance The financial proposal is based on part funding from membership subscription and part from key strategic organisations (i.e. AHSN). Member subscriptions will generate just over £1M or 50% of the LCA operating budget and a pragmatic view is taken on the differential between cancer centres (£120K) and cancer units (£40K) ratio 3:1. Furthermore the proposed subscription rates were indicative and could change depending on the LCA attracting investment from other sources. The Trust was supportive of this approach and commented that the subscription charges should broadly correlate with levels of income generated. 2.3 Governance Three options were presented for strengthening and changing the Members Board.

• Include all CEOs members on the Board • Expand CEO membership specifically with cancer units and develop a

model for rotational membership. In additional create a members council (all members) meeting twice a year

• Either of the options above plus two NEDs.

4

In light of the changing landscape and to strengthen the Trust’s profile in terms of cancer services, support was given to option one. 3. Outcome of the consultation The value proposition and proposed introduction of members subscription was discussed at the LCA board meeting on the 23rd January 2014.

• 13 out of 15 possible responses had been received with 2 further expected • All but two responses (from cancer units) supported the introduction of a

subscription • 7 responses supported all CEOs being on the board; 4 responses support

a smaller board with increased cancer unit CEO representation plus a member’s council; 1 indicated they would support the majority view whilst another expressed no view.

• 3 responses support the introduction of NEDs. A few respondents quite reasonably raised questions about the value proposition, the proposed subscription level/LCA’s costs and value for money. The Board accepted that these questions and agreed not to delay implementation of the proposal and subscription charge. The questions will be addressed at the next LCA Members Board meeting in March. The conclusion of the Board discussion was to:

• Accept the value proposition for members. • Introduce annual member subscriptions of £120,000 and £40,000 for

centres and units respectively from 1 April 2014. • Enlarge the board to include all CEO members, meeting every two

months. Recommendation to the Board The Board is asked to: 1. Note the outcome of the consultation describing the benefits that would arise

out of the membership changes proposed and implications of the subscription charges.

2. Continue to support the Trust’s membership of the LCA in light of these changes.

5


26th March 2014


REPORT TO: Trust Board REPORT FROM: Theresa Murphy, Director of the Patient Experience and Nursing DATE: 26th March 2014 SUBJECT: Review of the Trust’s Quality Governance Systems Trust Strategic Priority • To create a patient centred organisation to deliver improvements in patient

experience and the quality of care we provide. • To deliver high quality care in the most efficient way. Summary: As per the terms of reference agreed by the Board in September 2013, KPMG conducted an independent assessment of the Trust’s performance against the four domains and the ten questions in Monitor’s Quality Governance Framework. The final report was received in February and discussed at a Board Strategy Session. The review itself comprised of:

• A full review of the self-assessment of the Trust • Assessing the evidence collected by the Trust to support its updated self-

assessment • Extensive interviews across the Trust • Collective feedback form staff, internal and external stakeholders • Observation of sub committees of the Trust Board.

The key findings of the report gave the Trust a score of 2.5 and noted that there is evidential proof of strong systems and processes in place. The report found that the strength of challenge at the Trust Board and the Sub Committees was both robust and appropriate. The report noted that there is a culture amongst senior staff and the Board of openness where problems are accepted, and the focus is on finding solutions. The executive summary and key findings are attached. The report gave the Trust an opportunity to enhance quality governance by prioritising key areas of focus. It identified a number of recommendations for how the Trust could further strengthen its quality governance arrangements. The Executive Team have discussed these and identified the lead Executives for taking each of

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these forward. A single action plan will be coordinated by the Executive Director of Patient & Experience’s team and presented to the Board later in the year. Board Action Required: The Board is asked to: 1. Formally note the findings and recommendations of the independent Quality

Governance Review. 2. Support the work to develop an action plan for a future Board update.

2

3 This document is CONFIDENTIAL and its circulation and use are RESTRICTED. © 2014 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG Europe LLP and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved. Printed in the United Kingdom.

Executive summary Background and finding summary

Scope and approach

As per the Engagement Letter, we have carried out an Independent assessment of the Trust’s performance against the four domains and ten questions in Monitor’s Quality Governance Framework.

Between 7 January and 31 January, we:

■ Reviewed the self-assessment prepared by the Trust

■ Assessed the evidence collected by the Trust to support its updated self-assessment

■ Interviewed Trust Board members and Divisional Leadership

■ Collected feedback through staff and patient focus groups as well as through interviews with external stakeholders.

Findings

Our assessment found agreement with the Trust’s self-assessment in most of the domains in Monitor’s Quality Governance Framework. We have assessed the Trust’s overall score as being 2.5. The table at right highlights areas where we agree or disagree with the Trust’s self assessment.

Overall the quality governance systems and processes at Hillingdon Hospitals NHS Foundation Trust appear to be strong. During our work we noted some key strengths:

■ The strength of challenge at Trust board and in sub-committees was robust and appropriate and this extended into other meetings that are not formally part of the governance structure. Of note is the complimentary challenge and insight from the Non-Executives, and also the individual interest and depth of scrutiny over quality issues shown by all Board members.

■ Across all of our meetings and observations there is a general sense that the culture amongst senior staff and the Board is one of openness, where problems are accepted and the focus is on finding solutions – as opposed to a culture of defensiveness and self-protection.

Ref Quality Governance Question Trust Rating

KPMG Rating Score

1 a Does quality drive the Trust’s strategy? Amber/Green

Amber/Green

0.5

1 b Is the Board sufficiently aware of potential risks to quality? Amber/Green

Amber/Green

0.5

2 a Does the Board have the necessary leadership and skills and knowledge to ensure delivery of the quality agenda?

Green Green 0.0

2 b Does the Board promote a quality focused culture throughout the Trust?

Amber/Green

Amber/Green

0.5

3 a Are there clear roles and accountabilities in relation to quality governance?

Green Amber/Green

0.5

3 b Are there clearly defined, well understood processes for escalating and resolving issues and managing performance?

Green Green 0.0

3 c Does the Board actively engage patients, staff and other key stakeholders on quality?

Amber/Green

Green 0.0

4 a Is appropriate quality information being analysed and challenged?

Green Green 0.0

4 b Is the board assured of the robustness of the quality information?

Green Green 0.0

4 c Is quality information being used effectively? Green Amber/Green

0.5

Total 2.5

4 This document is CONFIDENTIAL and its circulation and use are RESTRICTED. © 2014 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG Europe LLP and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved. Printed in the United Kingdom.

Executive summary Background and finding summary

(continued)

■ The ‘on paper’ governance systems and processes are sound, but of greater importance is that the ‘spirit’ of those process appears in the main to be understood and welcomed.

■ There are some specific examples of good practice that should be shared outside the trust – such as including ‘specific terms of reference’ in the form of questions in the SI root cause analysis and the data quality markers on some of the board information packs.

We have largely agreed with the Trusts self-assessment and score – with some variation. There are, in our view, some key areas that the Trust should consider prioritising in order to enhance quality governance:

■ Accountability

– There are some ‘quick’ fixes around clarifying, for the whole Board, Executive accountability for some important areas (e.g. clinical audit, NICE guidance). Just as importantly, the Trust needs to be clear on how it will drive accountability at divisional level, in order exploit useful mechanisms such as clinical audit more effectively – making clear who is accountable for what outcomes.

– ‘On paper’ accountability at Divisional level is reasonably clear – but ‘heart felt’ accountability is much more variable and our observations suggest that it is too easily spread or avoided at present. The Trust already recognises this and the Executive has plans in development to help address it – but the inconsistency at Divisional level is one of the more notable issues we encountered and addressing it should be a priority.

■ Use of Information

– In our experience this is a difficult area to perfect, but what stood out in our observations was the variability in the way information was used at Divisional level. The board needs to know that information is used consistently at this level in order to feel assured that appropriate risks are being escalated and managed – but also to avoid ‘target driven’ behaviour. We observed inconsistent approaches to the information that was made available to the divisions – for example on the one hand a focus on ‘how to make the target /KPI better’ vs ‘we better understand if anything’s going wrong and fix it’ on the other.

– Some potentially useful information was disregarded at Divisional level in some of our observations. This may mean that the board does not have full or timely insight into all the key risks. This links back to the accountability issue – there does appear to be room for some emerging risks to be hidden or brushed aside – and suggests that the connection between the board and the divisions still needs some improvement.

■ Alignment

– The Trust does need to align the new quality strategy with the specifics within quality accounts, appraisals and performance management and look at co-ordinating some of the key tools (like clinical audit) so that the quality priorities and objectives are embedded throughout the Trust. It also needs to ensure that the latest quality strategy has full buy in from the service lines.

Quality Governance at the Trust appears good; however the Board needs to sustain its intentions in this area, particularly as more fundamental issues have an increasing impact – notably the estate, system financial pressure and major system strategies such as Shaping a Healthier Future.

HHT Quality Governance Review Questions Recommendations Lead 1a Does quality

drive the Trust’s strategy?

Recommendation 1: The Trust should bring together the strategic priorities, clinical quality priorities and indicators and quality account priorities into a coherent plan with consistent measures of success. This plan will need to be clearly communicated to all staff and understood from Board to Ward and the measures of success tracked and monitored at ward, department, divisional level and through to Trust Board.

TM (JW)

1b Is the Board sufficiently aware of potential risks to quality?

Recommendation 2: Where papers explicitly identify concerns, non-compliance or non-participation, the presenter explicitly draws this to the attention of the Committee.

All Execs (for their respective areas)

Recommendation 3: Although external risks to quality are considered in the BAF, the Trust should take time to consider the appropriate risk management strategy for the external risks to the organisation, which may need to feature in the Integrated Risk Register.

DS (HC)

Recommendation 4: The Trust should ensure that there is formal sign off of all QIPP initiatives by a clinical lead or Director and then the Nursing Director and the Medical Director. The suitably high risks associated with QIPP initiatives should be incorporated into the central risk management process.

KMO (SP & HC)

Recommendation 5: We would encourage the Trust to further develop the use of early warning indicators and agree thresholds to ensure maximum foresight of cost improvement scenarios that have a negative quality impact.

AK (JW & SP)

2a Does the Board have the necessary leadership and skills and knowledge to ensure delivery of the quality agenda?

Recommendation 6: In order to strengthen the delivery of the organisational imperatives, clear Executive accountability for actions should be identified in response to specific discussions.

SD / Chair

Recommendation 7: The Board should continue to build organisational capability on quality governance through a board development programme in which the Divisional leadership teams also have involvement.

SD / Chair (DC)

2b Does the Board promote a quality focused culture throughout the Trust?

Recommendation 8: The Trust should ensure that it is able to monitor the impact of organisational development initiatives on quality in a methodical way.

CG

Recommendation 9: The Trust should continue to build good governance behaviours such as scrutiny, challenge and robust action noting through coaching and shadowing at committees and forums.

CG

3a Are there clear roles and accountabilities in relation to quality governance?

Recommendation 10: We recommend that the accountabilities be clarified on all areas of quality governance from Board to ward or department, in the light of the proposed new clinical leadership structure. Executive accountability should be confirmed specifically for NICE guidelines, risk management and clinical audit where intervention is required to address the issues.

TM

Recommendation 11: The Trust should reconsider the need to establish a Chief Executive-led Management Executive to oversee all aspects of trust performance including cross-divisional consistency of the governance processes. In addition, a review of the terminology and meeting names may help to ensure the purpose and remit of these meetings are aligned.

KMO TM (JW)

3b Are there clearly defined, well understood processes for escalating and resolving issues and managing performance?

Recommendation 12: The Trust should build governance capability in the divisions and clarify the reporting structures within each.

TM (JW)

Recommendation 13: The Trust needs to embed the process of populating the Divisional Exception Report template across divisions. The Trust should ensure that feedback from the CGC is timely and relevant to divisional issues that have been escalated.

TM (JW)

Recommendation 14: The divisional templates that are being used for the CGC should be revised to contain explicit reference on outstanding incidents and assurance provided on how outstanding incidents are being managed.

TM (JW)

Recommendation 15: The Board should seek assurance that CARES are being embedded for all Trust staff and the values are being linked to complaints performance.

CG

3c Does the Board actively engage patients, staff and other key

Recommendation 16: The Trust should continue to develop its strategies for patient and stakeholder involvement at a divisional level, reviewing recruitment and engagement opportunities at divisional-level forums.

TM (CH)

stakeholders on quality?

4a Is appropriate quality information being analysed and challenged?

Recommendation 17: The Trust should link all relevant information (including individual consultant-level information) into the Trust Clinical Quality Strategy. This should support effective scrutiny at divisional level and integrate with the escalation process built into the Trust’s quality governance systems.

TM (JW & LH)

4b Is the Board assured of the robustness of the quality information?

Recommendation 18: The Trust should roll out the use of the Data Quality badge for each source of information provided at key committees.

PW (LH)

4c Is quality information being used effectively?

Recommendation 19: The Trust should build the quality governance capability across divisional teams with particular emphasis on the use of quality information to drive improved performance.

TM (JW)


26th March 2014

THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST REPORT TO: Trust Board REPORT FROM: Joe Smyth, Director of Operational Performance REPORT SPONSORED BY: Karl Munslow Ong, Chief Operating Officer Theresa Murphy, Director of Patient Experience

and Nursing DATE: 26th March 2014 SUBJECT: Quality and Operational Performance Report for

February 2014 Trust Strategic Priority: The report covers all of the Trust’s Strategic Priorities. Summary: This report provides the Board with an analysis of performance to the end of February 2014. The report covers performance against the Monitor Risk Assessment Framework as well as national and local key performance indicators. Board Action Required: The Board is asked to review the Quality and Operational Performance Report and the actions being taken. Equality Impact Assessment: N/A – there is no positive or negative impact from this report.

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Quality and Operational Performance Report for February 2014 1. Introduction The purpose of this report is to provide assurance to the Board on compliance against the Monitor Risk Assessment Framework, national and local key performance indicators. It acknowledges significant and notable achievements, and highlights and discusses areas of concern or where performance has a less than favourable forecast. 2. Items of Note 2.1 Bed Occupancy January and February are usually the busiest months of the year. Despite the milder winter, the demand on our inpatient bed base was as equivalent and on occasion greater than in previous years. The length of stay gains achieved through these months meant that the Trust had 16 fewer winter escalation beds open in February 2014 compared to the same period last year.

2

2.2 A&E report Performance against the four hour target was consistently achieved for each week during February. This was despite the additional pressure experienced in the department by a higher than average ambulance attendance (additional 5 per day). Year to date there has been an increase of 447 category A attendances (‘blue light’ ambulances) which adds to the workload of the clinical teams and clearly presents a challenge in terms of meeting the 4 hour standard. The perceived higher acuity of the patient cohort continues to correlate with an increase in occupancy of the resuscitation room when compared with 2012/13. Patients requiring the most acute level of care spend more time in the department due to clinical need which increases the likelihood of breaching the 4 hour standard.

4

During February there was a corresponding fall in the percentage of patients seen by the Urgent Care Centre (UCC) from 60% to 53%. This may have been due to patients presenting with a higher complexity of need that was beyond the remit and capability of the urgent care service. The UCC is currently seeing and treating a high percentage of paediatric patients but a far lower percentage of complex care of the elderly patients that by default often require a higher degree of intervention, stay longer in the department and subsequently require admission once stabilised. Overall, during February the Trust achieved 96.2% for all type performance and 90.4% for type 1 attendances (patients treated in the accident and emergency department only). Consistent achievement of > 95% for all type attendances continues to identify the Trust as a high performer across London. 2.3 Edmunds Ward As reported last month, Edmunds ward was opened in December 2013 to provide additional bed capacity for Northwick Park Hospital as part of the Winter Planning Programme. Originally commissioned until the end of March, this service has now been extended until the end of April 2014. To date 57 patients have been admitted to Edmunds ward. The majority (30) of these patients required ongoing rehabilitation services with the remaining (27) admitted while awaiting complex placements to be arranged. So far 25 patients have been discharged home or to a nursing-home placement. In total 10 patients have been transferred back to Northwick Park for medical reasons. As stated last month, it was always anticipated that some patients would deteriorate and need to be transferred back to an acute hospital and therefore a pathway was developed which continues to ensure the safe management of patients. This

5

pathway continues to work well and there are no reported delays in the repatriation of patients to Northwick Park. There has been very positive feedback from patients and carers in particular for the excellent care provided by the nursing and medical teams on the ward. The management team at Northwick Park have formally recognised the positive contribution that Edmunds Ward made to the ongoing care of patients transferred across. 2.2 Northwick Park Elective Work The Trust is continuing to support Northwest London Hospitals Trust (NWLHT) to delivery its elective work programme. To date the Trust has received 515 referrals. 359 patients have accepted to have their procedure undertaken at the Trust. 170 of these patients have already had their operation on the Mount Vernon Site. NWLHT has temporarily suspended transferring patients while they undertake a review of progress to date. It is likely that the transfers will restart in April 2014. 2.3 Winter Schemes The Trust is now undertaking a full review of all winter schemes and the impact they had on enhancing patients’ flows. A number of schemes have already been identified as having made a positive contribution to achieving the 95% four hour A&E standard over the winter period. These include additional senior on site managerial cover out of hours, extra medical and nursing staff and enhanced medical cover on the wards over the weekend. Potentially there may be additional winter monies to support Trusts to de-escalate schemes gradually. The Trust has submitted a list of schemes to the CCG that it would wish to continue to support while funds were available. 3. Quality Report Narrative Patient Safety Indicator (04) – Hospital Acquired Infections C. difficile The Trust reported one C difficile infection for February 2014 bringing the total reported cases to 12 for the year. Whilst we are close to the annual objective of 14 we remain vigilant with sampling and continue the work on antimicrobial stewardship. The ‘Start Smart then Focus’ guidance and its subsequent action plan continue to be developed. The audit programme for antibiotic compliance has recently changed from monthly to quarterly. The frequency has been changed in collaboration with the clinical audit department and ensures that with the new quarterly data an action plan from divisions will be required to address low compliance. A recent meeting with the Assistant Directors of Operations (ADOs), Nursing Services Managers (NSMs) and Clinical Directors (CDs) strengthened the focus on antimicrobial prescribing with a

6

commitment from specialties to undertake their own audits using a Trust template. This will provide data specific to the specialty in order to drive performance. Carbapenemase-producing Enterobacteriaceae The Trust has received both a letter from Public Health England (PHE) and a Patient Safety Alert in relation to Carbapenemase-producing Enterobacteriaceae and other carbapenem-resistant organisms. Enterobacteriaceae are a large family of bacteria that usually live harmlessly in the gut of all humans and animals, but, in the wrong place, can cause serious infections. Worldwide, a small but increasing number of strains of Enterobacteriaceae have become resistant to carbapenem antibiotics, which have been defined by WHO as critically important antibiotics. Increasing trends in sporadic infections, clusters and outbreaks of carbapenemase-producing Enterobacteriaceae (CPE) have been observed in a number of NHS Trusts in England. There is a high risk of this problem becoming more widespread unless early and decisive action is taken by Trusts as these bacteria represent a significant challenge in terms of prevention, treatment and control. In the UK, we have a window of opportunity to prevent widespread problems caused by these organisms. Whilst we are seeing increasing numbers of carbapenemase-producing Enterobacteriaceae, we have not yet reached the escalated situation seen in other countries. As a precaution the letter from PHE and the alert have been disseminated and the Infection Prevention and Control Team are reviewing current policies and practice to ensure we meet these new recommendations and will provide a full update for the next trust board meeting. 2014/15 Healthcare Associated Infections Objectives As we come to the end of the year new objectives for 2014/15 are established. As with this year NHS England remain focused on a zero tolerance of MRSA blood stream infections and have set the same objective as this year-zero. This is a very challenging target which we exceeded by one this year, and whilst this has seen a consistent performance for the organisation clearly we want to achieve zero. From April 2014 NHS England regional teams will take on the role of arbitrating disputed MRSA bacteraemia cases which is currently held by Local Authority based Directors of Public Health. NHS England and Public Health England have noted that the rate of improvement for C diff has slowed over recent years. There are indications that for some organisations at least, C diff levels may be approaching their irreducible minimum level at which these infections will occur regardless of the quality care provided. Experts have now advised that a more flexible approach is now needed to objectives. The new changes are primarily focused on further encouraging organisations to look at each case they identify in order to understand what lessons they are able to learn in order to improve patient safety. Trusts have been divided into three cohorts for the purpose of calculating median C diff rates; these are:

7

• Teaching acute trusts • Non-teaching acute trusts • CCGs.

The new calculated objective for Hillingdon Hospital as classified under a ‘normal acute trust’ is 16; this is a CDI rate of 12.5 cases per 100,000 bed days. Financial sanctions for exceeding the objective are £10,000 for each case. Patient Safety Indicator (05) - Patient Falls The falls rate remains above the Trust target of 4.6 per 1000 bed days, having increased to 6.4 in February. The majority of increases occurred on Beaconsfield East, Hayes and Trinity wards. Churchill ward has recently transferred back to Beaconsfield East post refurbishment and it is thought that the layout of the ward (bays) may be a contributory factor to the increase in falls (from one last month to eight in February), due to lack of patient visibility from the nurses station. The Matron is currently considering the use of portable, multi-positional tables so that a member of staff can be based in each of the bays. Recently on Hayes ward there has been a very high level of patients with dementia and/or high dependency who are at high risk of falls and requiring constant supervision, which may have contributed to the increase in falls from five in January to 12 this month. The Trust is currently conducting an acuity and dependency assessment in order to review establishment and skill mix for each ward. Two low rise beds are currently in use on Hayes and it is hoped that these will prevent injury to patients at risk of falling from bed who are unsuitable for bed rails. Falls on Trinity ward increased from four the preceding month to eight in February. Although no strong themes were identified on investigation of the falls, non-slip slipper socks are not currently being used on the ward and it has been recommended that these are introduced. On a positive note, Edmunds ward at Mount Vernon experienced a reduction in falls this month, from eight the previous month to three in February. This is probably due to a combination of better staff continuity on the ward coupled with a recent decrease in the number of patients requiring constant supervision. There were two falls resulting in fractures this month, for which Root Cause Analysis investigations have been completed in line with the Trust falls policy. Although the falls occurred at different times of day, the investigations identified some common contributory factors. Both patients were assessed as being at high risk of falls and were confused due to their medical condition at the time of the falls. Each patient was placed as near to the nurses station as possible and given a call bell but neither was able to comply with instructions due to their confusion. The falls were both unwitnessed – in one case due to lack of handover by a member of bank staff before going off duty. Actions identified as a result of the investigations are focussed on supervision of high risk patients and staff communication, especially during handover. Concerns about night staffing on Hayes were also raised and will be considered during acuity and dependency assessments.

8

As a result of the increase in the number of falls in February falls prevention and management has been the focus of discussions with the Senior Sisters/Charge Nurses and Matrons at recent nursing quality performance meetings with the Deputy Directors of Nursing. Patient experience Indicator (19) - Complaint Response Rate 100% of complaints received in February were acknowledged within three days and Complaint Management Plans were agreed with 35 complainants. 36 complaint responses were due in February; a response rate of 86.1% was achieved. This represents a significant improvement from January and gives a good foundation for achieving and sustaining the Trust target of 90%. Division % Commentary CCSS

100%

Due – 9 Achieved - 9 Breach - 0

The themes from the complaints concern communication about appointments and changes of appointments. The division have this month changed the wording of text messages sent to patients to remind them about their outpatient appointment to include the speciality of the appointment they are attending in hope that information about appointments is clearer.

W&C

75% Due - 4 Achieved - 3 Breach - 1

The breach was due to a complex complaint involving both Hillingdon Hospital and the Brompton Hospital and multiple specialties. Themes from the complaints were: two complaints querying potential missed diagnosis; one complaint with regards lack of information; and one complaint with regards to not being able to get through to clinical staff.

The division continues to work hard to improve the access to information and clinical people for both the patients and GPs. The division is updating its websites to try and provide relevant information.

Surgery

87.2%

Due - 11 Achieved - 9 Breach - 2

Both breaches occurred as the first response was inadequate and had to be returned to respondent for further clarification. The division continues to monitor and track all complaints and discusses and identifies trends at the Divisional Management Board.

9

Medicine

77.4% Due - 9 Achieved - 7 Breach - 2 Breaches due to late information from medical staff (1), a reply letter needing a rewrite requested by the Exec team (1). Themes included poor communication from all staff groups, lack of care or compassion from A&E staff and poor care standards.

The division continues to push the CARES values with all staff completing and being involved in the recent CARES drive. The division is also pushing customer care courses and promoting accurate feedback to areas with high complaints.

Outpatient Experience: The overall outpatient experience dipped to 86% during February having been maintained at 88% during December and January. Interestingly the number of responses during February was slightly lower than normal (504 compared to 600). The kindness, courteous and helpful behaviours of staff stood out as an area of high performance. The key areas for improvement concerns providing the patient with a copy of the letter between the hospital consultant and GP about their care and treatment. This aspect of the patient pathway is under review. Other actions currently being taken to improve overall satisfaction concern the environment, upgrading the main Outpatient Department entrance with a new reception area and volunteers to direct patients and carers, and communication with patients about their follow up care and who to contact following their appointment.

10

Complaint Trends The graph below shows the Trust wide top ten complaint subjects in February.

02468

10121416

February Complaints Top 10 subjects- Trustwide

Clinical care (medical staff) remains the most frequently occurring subject code. In the Women’s and Children’s Division, a complaint investigation identified that the pathway for babies diagnosed with heart murmurs is appropriate. To ensure that any learning is shared this case will be discussed at divisional governance forums. In the Surgical Division, a complaint investigation identified that the correct note tracking procedure was not followed. The end outcome of this led to the cancellation of a surgical procedure. A letter has been written to all staff highlighting this case, outlining the incident and the impact this had. The incident will also be discussed at the Divisional Executive Meeting where all managers and clinical leads attend, ensuring that they disseminate this incident to help prevent this situation occurring again.

4. Monitor Performance Framework Compliance against the Monitor Performance Framework remains strong, and all indicators were achieved for February 2014. 5. Contract KPIs Indicator 15 – Total Time in A&E 95th percentile (A) Target < = 4 Hours With UCC Excluding UCC February TBC 5Hrs 16Min Year to date TBC 4Hrs 52Min

11

IT systems used by the UCC are currently unable to provide the necessary information to facilitate reporting of this indicator. Senior management for the UCC are working towards resolving this issue. The total time spent in A&E has increased during February and links to the higher acuity of patients. In the interests of patient safety there is a requirement for patients to be physiologically stable prior to transfer to a ward. There remain some ongoing issues with patients being referred late from the UCC which impacts on the ability of the emergency department team to see and treat within the 4 hour target. In total, 37 patients were referred late to the emergency department from the UCC and subsequently breached the four hour target. Indicator 17 –Time to Treatment (A) Target < = 60 minutes With UCC Excluding UCC February TBC 1Hr 37 Min Year to date TBC 1Hr 28 Mins

Performance against this indicator is being adversely affected by the number of transfers from the UCC. Over the past three months the number of transfers from UCC has been steadily increasing, as illustrated by the graph below.

During December on average UCC referred 170 patients per week. This has increased to an average 189 referrals in February. This equates to 27 patients per day. During February there was a 12% increase in referrals from the UCC compared with January. Patients seen in the UCC and then referred into the A&E will already have waited more than 60 minutes to be seen. The senior clinician and manager for A&E are working closely with colleagues in the UCC to understand why there was such as significant increase in referrals and to improve pathways for patients who subsequently require a higher level of care.

12

Indicator 18 - A&E Unplanned Re-attendance (A) Target < = 5% With UCC Excluding UCC February TBC 8.9% Year to date TBC 8.3%

The unplanned reattendance rate has remained fairly static throughout the preceding 12 months. A number of patients present at the A&E department on a regular basis. These patients are identified for additional support by CNWL and via initiatives such as the integrated care pilot. The pilot seeks to develop bespoke care plans for patients with a high complexity of need. There is however a recognition that some individuals have preferred patterns of behaviour (when accessing healthcare) that may be intractable regardless of concerted efforts to provide alternative pathways of care. Indicator 20 – Cancelled Operations (A) Target February Year to date <0.80% 1.42% 0.85% This measure focuses on patients that had procedures cancelled on the day of their operation. This standard has not been achieved this month as a surgeon became ill on day of operating resulting in the cancellation of an all-day list. Due to unavoidable circumstances another consultant had to take extended leave at short notice. This also resulted in the cancellation of another all day list. A locum consultant has now been employed to cover this extended leave. Indicator 23 - Ambulance arrival field complete (A) Target February Year to date > = 95% 93.2% 93.7% There has been a significant improvement against this target over the past few months as a consequence of robust monitoring of performance. Regrettably the increased activity in the department has impacted performance against this standard during February. Administrative staff have now been deployed to the emergency first assessment area to assist clinical personnel with the completion of essential data entry tasks. Indicator 24 – DQ Seen by clinician for treatment time field complete (A) Target February Year to date > = 95% 93% 93.5% Increased use of locum staff during the winter period continues to adversely impact on the achievement of this indicator. Each locum doctor has a local induction where the importance of data completion is emphasised. Obtaining traction with locum staff remains challenging. Senior clinical leads have been requested to reinforce the necessity for all staff to complete relevant data fields. Indicator 30 – Emergency re-admission within 30 days (R) Target February Year to Date 6.5% 9.1% 7.8%

13

Overall readmission rates across the Trust have remained fairly static over the last 3 years; 2011/12 7.5% 2012/13 7.8% 2013/14 7.9% To investigate the causal factors behind readmissions, and to underpin the development of strategies to decrease the number of readmissions in the future, a retrospective audit was carried out during December 2013. The audit was conducted by two clinicians who looked back through available case notes for patients who had been readmitted during week one of April, July and September 2013. 128 patient case notes were audited, of which 11 had more than one readmission episode, this equated to a total of 139 readmission episodes. 91 (65%) of the total 139 readmissions were noted as unavoidable, with 48 (35%) avoidable. Failure in communication was the biggest contributor to the avoidable readmissions (33/48, 69%). The audit also identified that 16 (12%) readmissions may have been avoided with medication support. It should be noted that the 35% identified as being avoidable were determined as being so given current models of care at the time of the readmission. New models of care have since been introduced, including the Emergency Ambulatory Care Pathway and the HomeSafe Early Supported Discharge pathway. As these, and other schemes, are developed and expanded, they are expected to contribute towards a reduction in readmissions. The full audit report is being shared with multiple stakeholders including the Trust’s Clinical Governance Committee and Quality and Risk Committee, Clinical Directors, ADOs, local GPs and the Hillingdon Integrated Care Group. This audit will feed into discussions to create a multi-agency action plan that supports a whole systems approach to developing integrated improvement plans aimed at reducing readmissions. Indicator 31 – Theatre Utilisation Target February Year to Date Utilisation

85%

80% 83.1%

Productivity

95% 76% 78%

Average case per session

3.3% 3.4% 3.7%

Cancellations <0.8% 1.42% 0.85%

The productive operating theatre group continue to monitor number the key performance indicators which are now being reflected in the Trust Performance

14

Report. These standards have been developed in conjunction with Newton Europe and aim to provide a more detailed picture on how Theatres are performing. The utilisation and productivity standard for February was not achieved. There was higher than usual short notice sickness and consultant unavailability. This resulted in a number of lists being cancelled on the day of surgery. Consultant long term absence also meant that a number lists had to be cancelled with only a few days notice. This had an impact in productivity as there was insufficient time to replace these lists with other activity. The Trust has now appointed a locum consultant to help elevate this pressure and to provide sessions where consultants are absence. In addition to the above standards the Productive Theatre Group continue to monitor, theatre start times, average operation times and numbers and cause of over running lists for each individual consultant. These figures are pro-actively managed with the consultants involved ensuring their engagement in the process. Indicator 32 – LAS 30 minute waits (new indicator for 13/14) (A) Target February Year to Date 100%

92.8 % 133

94.8% 1016

The shift coordinator and lead for emergency first assessment closely monitors patients as they arrive via LAS. Every effort is made to ensure that patients are assessed within the first 15 minutes of arrival. However during times of peak pressure, when ambulances arrive in batches, cubicle capacity is inadequate to cope with demand. Unfortunately this does result in some patients waiting for more than 30 minutes to be placed in a cubicle. Another contributing factor is the inadequate size of ambulance off-loading area. This area has insufficient capacity to effectively receive patients during peak operating times. In the longer term a new build will resolve these issues. In the meantime the department is undertaking a review of patient flows to see if off-loading times can be improved. Indicator 37 – Re-admissions within 28 days (A) Target February Year to Date < 100 102.0 (97.9 – 106.4) 102.0 (97.9 – 106.4) These figures are derived from Dr. Foster information and cover the period April to November 2013. The benchmark is always 100, values grater then a 100 represent performance worse than expected. These ratios should always be interpreted in line with the accompanying confidence limits. The Trust consistently remains within the confidence limits. Indicator 40 – Breastfeeding initiation (A) Target February Year to Date > = 85% 80.6% 82.2%

15

There has been a significant rise in performance year on year from 75% in 2010/11. The division is now implementing the first step towards achieving Baby Friendly Status. The Baby Friendly Initiative is a worldwide programme of the World Health Organization and UNICEF. It is anticipated that this 10 step programme will assist in achieving higher initiation rates. Indicator 45 – STaM% (R) Target February Year to Date 80% 59.92% 59.92% People and Development are now working closely with the clinical divisions to identify all individuals who have outstanding training requirements. These individuals will be contacted and given eight weeks to get their training up to date. Additional training sessions will be made available and individuals that fail to attend will be subject to a disciplinary process. There has been a modest improvement (3%) in compliance over the past two months.

16

The Hillingdon Hospital Trust Performance Report For the Month of Feb 2014 (Monitor KPIs)

2012/2013

Performance

Feb

Performance

Year-to-date

Performance

2013/2014

Target

Year End

Forecast

Monthly

Movement

Lead

Exec

Monitor

governance risk

weighting if in

breach

Current

Month

weighting

Current

Month

Traffic

Light

Q1

Actual

Q2

Actual

Q3

Actual

Q4

Forecast

DQ

Badge

Monitor Risk Assessment Framework (13/14 Q3 onwards confirmed): Access and Outcomes metrics

1 Clostridium Difficile Infection 23 1 12National: 14

(de minimis : 12)14 D TM 1.0 0

2Cancer: Maintain two week cancer waits

(all cancers) +^97.9% 97.1% 97.9% 93% 98% S KMO

3Cancer: Maintain two week cancer waits

(breast symptoms except suspected cancer) +^98.0% 93.7% 95.0% 93% 95% D KMO

4All cancers: 31 days diagnosis to treatment for cancer

(1st Treatment) +^99.2% 100.0% 99.3% 96% 99% S KMO 1.0 0


(2nd or Subsequent Treatment - Surgery) +^100.0% 100.0% 100.0% 94% 100% S KMO 0


(2nd or Subsequent Treatment - anti cancer drug treatments) +^100.0% 100.0% 100.0% 98% 100% S KMO 0

7 All cancers: 62 days urgent GP referral to treatment for cancer +^ 93.3% 92.0% 89.4% 85% 90% D KMO 0

8All cancers: 62 days urgent referral to treatment for cancer

(Screening) +^93.9% 100.0% 97.7% 90% 95% S KMO 0

9Referral to treatment waiting times

(admitted)97.5% 96.7% 97.2% 90% 98% I KMO 1.0 0


(non-admitted)98.8% 98.5% 98.6% 95% 99% S KMO 1.0 0


(incomplete)97.3% 96.3% 97.4% 92% 97% D KMO 1.0 0

12A&E: Total time in A&E less than 4 hours

(A&E, MIU, UCC)96.7% 95.9% 95.9% 95% 95% D KMO 1.0 0

13Self certification against compliance with requirements regarding access to

healthcare for people with a learning disability

Fully

Compliant

Fully

Compliant

Fully

Compliant

Fully

Compliant

Fully

CompliantS TM 1.0 0 N/A

0.0 0.0 0.0 0.0 0.0

No Governance

Concern

Evident

Regulatory

Action

1.0

1.0 0

1.0

Notes:

Monitor's Governance Rating under its RAF is now based on 5 categories (CQC Information, Access & Outcomes Metrics, Third

Party Reports, Quality Governance Indicators and Financial Risk). The 13 indicators above reflect the Access & Outcomes

Metrics only.

The Second Page of the Glossary details the triggers for concern and the steps that lead to a specific Governance Rating. As

there are numerous sources of information that will be used to derive the rating, it is not possible to give the full rating on this

scorecard and so the rating that is reported here is based purely on the 13 indicators above. Key triggers in relation to those 13

indicators are:

[a] 3 consecutive quarters' breaches of a single metric or a service performance score of 4 or greater.

[b] Breaching pre-determined annual C. difficile threshold (either 3 quarters' breach of the year-to-date threshold or breaching the

full year threshold at any time in the year)

[c] Breaching the A&E waiting times target in two quarters over any 4 quarter period and in any additional quarter over the

subsequent three quarters

+ Indicator reported one month in arrears, ++ Indicator reported two months in arrears

^ Whilst Cancer Indicators are reported with a one month lag, the Current Month Traffic Light Column is based on the latest

complete month available

Monitor identifies potential material

causes for concern in one or more

categories (requiring further

information or formal investigation),

Monitor will replace the green rating

with a description of the issue and

steps taken to address it

Traffic Light Key: [] - On target [] - Narrowly missing target [] - Significantly missing target

Performance Movement Key: I - improvement S - static D - deterioration

The Hillingdon Hospital Trust Performance Report For the Month of Feb 2014 (Contract KPIs)

2012/2013

Performance

Feb

Performance

Year-to-date

Performance

2013/2014

Target

2013/2014

Traffic Light

Year End

Forecast

Monthly

Movement

Lead

ExecComments Glossary

Quality: Safety

14 Obstetric 3rd/4th degree tears 2.8% 1.90% 1.99% <5 % 2% I AK/RGM RCOG target Obstetric 3rd/4th degree tears as a percentage of deliveries

Quality: Effectiveness

15 A&E: Total time in A&E (95th percentile) A&E excl / incl UCC4h 13m

/ 3h 59m

5h 16m

/ tbc

4h 52m

/ tbc<= 4h 0m 4h 0m D KMO

The 95th percentile time spent in the A&E department, for all patients. Excludes planned

return visits. (MIU data not included)

16 A&E: Time to initial assessment (95th percentile) A&E excl / incl UCC7m

/ 8m

4m

/ tbc

4m

/ tbc<= 15 minutes 15m S KMO

The 95th percentile time from arrival to start of full initial assessment, which includes a

brief history, pain and early warning scores (including vital signs), for all patients arriving

by emergency ambulance. (MIU data not included)

17 A&E: Time to treatment decision (median) A&E excl / incl UCC1h 30m

/ 1h 10m

1h37m

/ tbc

1h 28m

/ tbc<= 60 minutes 1h 0m D KMO

The median time from arrival to start of definitive treatment by a decision-making clinician

(someone who can define the management plan and discharge the patient) (Excl. MIU)

18 A&E: Unplanned reattendance rate A&E excl / incl UCC7.9%

/ 6.1%

8.9%

/ tbc

8.3%

/ tbc<= 5% 5% D KMO

Unplanned re-attendance at A&E within 7 days of original attendance (including if referred

back by another health professional) (MIU data not included)

19 A&E: Left without being seen A&E excl / incl UCC4.2%

/ 3.2%

2.5%

/ tbc

3.7%

/ tbc< 5% 5% D KMO

The percentage of people who leave the A&E department without being seen (MIU data

not included)

20Cancelled operations: operations cancelled for non clinical reasons

on day of admission or after admission. 0.61% 1.42% 0.85% <0.8% 0.8% D KMO

Ratio of Cancelled Operations (meeting all SITREP - Situation Reports - criteria) to

Elective Inpatient activity.

21Patients not readmitted within 28 days of cancellation for non-clinical

reasons on day of admission or after admission.6.0% 0.0% 0.0% 0% 0% S KMO

% of Cancelled Operations (meeting all SITREP - Situation Reports - criteria) which do not

get re-admitted within 28 days

22

Early access for women to maternity services by 12 weeks 6 days of

their pregnancy

[all] (excl late refs)

[80.4%] (93.2%) [83.2%] (98.5%) [82.6%] (96.6%) 95.0% 93% I KMO% of bookings having had a contact with service within 13 weeks of the booking.

Exclusions apply to referrals after 10+6 weeks.

23Data quality indicator for Indicator 24: Initial Assessment Time for

ambulance arrivals field completed92.0% 93.2% 93.7% >=95% 95% D KMO

Percentage of 'Initial Assessment Time for ambulance arrivals' field completed (UCC data

not included)

24Data quality indicator for indicator 25: Seen By Clinician for Treatment

Time field completed93.7% 93.0% 93.5% >=95% 95% D KMO

Percentage of 'Seen By Clinician for Treatment Time' field completed (UCC data not

included)

25First attendances at GUM service who were offered an appointment

within 48 hours100.0% 100.0% 100.0% 100% 100% S KMO

% of first attendances in month who were offered an appt to be seen within 48 hours of

contacting patient request (via telephone).

26 Maximum two-week wait for Rapid Access Chest Pain Clinics 100.0% 100.0% 100.0% >= 98% 98% S KMO% of patients with a GP Referral to a RACPC seen within 2 weeks. The standard only

applies where the referral is received by the clinic within 24 hours of GP deciding to refer.

27Percentage of individual specialties achieving Admitted and Non-

Admitted (excluding Audiology) 18 week Targets99.4% 100.0% 100.0% TBC 100% S KMO

Percentage of individual specialties achieving Admitted and Non-Admitted (excluding

Audiology) 18 week Targets

28 Percentage of patients waiting >6 weeks for a diagnostic test 0.003% 0.00% 0.003% <1% 1% S KMO Percentage of patients waiting over 6 wks for diagnostic tests at month end

29All cancers: 62 days urgent referral to treatment for cancer

(Consultant Upgrade) +98.6% 96.1% 96.5% >=85% 96% D KMO

Other

30 Emergency readmission within 30 days of discharge 7.8% 9.1% 7.8%To be set following

CCG Audit7.8% D KMO

Methodology taken from PBR Guidance - note that denominator also does not include

PBR excluded activity for consistancy. Major Exclusions are patients aged <4 years old,

patients with a cancer diagnosis & maternity patients

31 Theatre Utilisation (Newton Methodology) 79.0% 80.0% 83.1% 85% 83% D KMO

32 LAS Handover 30 min waits (actual / %) n/a 133 / 92.8% 1016 / 94.8% 100% 95% D KMO Sourced from LAS Portal

The Hillingdon Hospital Trust Performance Report For the Month of Feb 2014 (Local KPIs)

2012/2013

Performance

Feb

Performance

Year-to-date

Performance

2013/2014

Target

2013/2014

Traffic Light

Year End

Forecast

Monthly

Movemen

t

Lead

ExecComments Glossary

Safety

33Stroke: Percentage of patients that have spent at least

90% of their time on the stroke unit99.6% 100.0% 97.5% 80% 80% I KMO

34Stroke: Percentage of high risk TIA patients who are

treated within 24 hours100% 100% 100.0% 75% 75% S KMO

35Fractured neck of femur patients in theatre within 36

hours. +88.4% 95.2% 92.4% 90% 90.0% I AK/RGM

Fractured Neck of Femur (FNOF) patients operated on in theatre within 36 hours of admission as a % of total

FNOF patients. Reported with a one month lag.

36 Caesarean section rate (Elective), [Non Elective]27.13%

(9.57%)[17.56%]

28.25%

(8.25%)[20.0%]

26.93%

(9.7%)[17.23%](12%) [15%] 12% / 15% D AK/RGM

Elective and Non Elective caesarean sections as a percentage of all deliveries. Target is Royal College of

Obs and Gynae recommendation

37Readmissions within 28 days (benchmarked and casemix

adjusted) +++

105.2

(102.3 - 108.3)

102.0 (97.9 -

106.4)

102.0 (97.9 -

106.4)<100 105 I

KMO/

AK/RG

M

Monthly & YTD

figure is for Apr-

13 to Sep-13

Derived by Dr Foster. The benchmark is always 100, hence values greater than 100 represent performance worse than the

benchmark, and values less than 100 represent performance better than the benchmark. This ratio should always be

interpreted in the light of the accompanying confidence limits. It is standardised for diagnosis/procedure, subgroup,

admission type, age, sex, deprivation, month of admission (for some respiratory diagnoses) and year. Important note:

When analysing readmissions, admissions for the last 3 months (based on discharge date) are excluded. This is because it

is impossible to calculate the outcome with any degree of certainty due to the time lag involved. We allow 1 month for the

patient to be readmitted, 1 month for the patient to be discharged and 1-2 months for the data to be submitted to SUS

(Secondary Uses Service - National database of hospital activity).

38 Trust Incidents Reported under RIDDOR 13 2 28 TBC 30 I DSTrust incidents resulting in notification to the Health and Safety Executive under the Reporting of Injuries, Diseases and

Dangersous Occurances Regulations (RIDDOR). 2012/2013 is based on a 7 day period

Effectiveness

39

Infant health & inequalities: smoking during pregnancy9.2% 6.7% 7.8% <10% 10% D KMO Actual percentage of smoking mothers

40

Infant health & inequalities: breastfeeding initiation83.7% 80.6% 82.2% >=85% 85% D KMO Actual percentage of breast feeding mothers

Other

41 Personal Development Review (PDR) coverage 90.1% 83.9% 83.9% 90% 84.0% S CG New PDR Cycle started from April 2013.

42 Trust sickness rate + 3.35% 3.09% 3.14% 3% 3.1% I CG Jan Data

43 Trust vacancy rate 8.33% 8.36% N/A 8% 8.0% S CG Jan Data

44 Turnover rate 10.79% 0.59% 10.76% n/a 10.0% I CG Jan Data

45 STaM % 69.30% 59.92% 59.92% 80% 80% D CG Jan Data

Feb 2014: The STaM figure is now populated from WIRED (excluding Local and Corporate Induction data)

and based on the new Training Matrix.

46 ER Cases 69 2 65 n/a 65 S CG Jan Data

47 Medical Staff Appraisals 30.40% 51.18% 51.18%

100%

(by 31st

March)

n/a I RGM Jan Data

48 Response Time to FOI 80.0% 75.0% 76.0% n/a 75.0% D DS FOI requests have a 20 working day turn around before they breach

Glossary - Feb 2014

Monitor Compliance Indicator Description Monitor Compliance Notes DQ Comments

1Clostridium Difficile Infection

Inpatients with Specimens taken after 48 hours (attributable to Trust)Monitor’s annual de minimis limit for cases of C. difficile is set at 12

External Deloitte audit May '11 assessed data as

'Green'; meeting all key standards and aspects of data

quality. Internal October 2013 data quality audit rated

'well above minimum requirements'.

Rating remianed the same.

2Maintain two week cancer waits (all cancers)

% of patients with an 'Urgent GP referral' having been 'First Seen' within two weeks of referral.

3

Maintain two week cancer waits (breast symptoms except suspected cancer)

% of patients first seen by a specialist within two weeks when urgently referred by GP with any breast

symptom except suspected cancer.

4

31 days diagnosis to treatment for cancer (1st Treatment)

% of patients receiving first treatment within a maximum waiting time of 31-days from decision to treat,

including patients with a recurrent cancer.

The target will not apply to trusts having five cases or fewer in a quarter. Monitor will not score trusts failing individual

cancer thresholds but only reporting a single patient breach over the quarter.

5

31 days diagnosis to treatment for cancer (2nd or Subsequent Treatment - Surgery)

% of patients receiving subsequent treatment (surgery) within a maximum waiting time of 31-days from

decision to treat, including patients with a recurrent cancer

6

31 days diagnosis to treatment for cancer (2nd or Subsequent Treatment - anti cancer drug

treatments)

% of patients receiving subsequent treatment (drug) within a maximum waiting time of 31-days from

decision to treat, including patients with a recurrent cancer

7

62 days urgent GP referral to treatment for cancer

% of patients receiving first definitive treatment within 62-days of referral, following an urgent referral

from a GP

8

62 days urgent referral to treatment for cancer (Screening)

% of patients receiving first definitive treatment within 62-days of referral, following a referral from an

NHS Cancer Screening Service

9Admitted Pathways

% of patients that had treatment completed as an Inpatient within 18 weeks

10Non-Admitted Pathways

% of patients that had treatment completed in a setting other than Inpatients within 18 weeks

11Incomplete Pathways

% of patients waiting for treatment waiting less than 18 weeks

12Total time in A&E less than 4 hours (A&E, MIU, UCC)

% of patients waiting less than 4 hours in A&E from arrival to discharge

Waiting time is assessed on a site basis: no activity from off-site partner organisations should be included. The 4-hour

waiting time indicator will apply to minor injury units/walk in centres.

This data is validated daily & weekly in time for the

weekly SITREP return. In line with DH & Monitor

requirements, the Trust is expected to incorporate and

submit UCC data as part of Trust returns.

Audit - Internal October 2013 audit rated as 'Urgent

Action Required'. Four, 4 hour breaches found.

Timeliness is within 24 hours of activity for all records

but not real-time.

13

Self certification against compliance with requirements regarding access to healthcare for

people with a learning disability

Meeting the six criteria for meeting the needs of people with a learning disability, based on

recommendations set out in Healthcare for All (DH, 2008)

NHS foundation trust boards are required to certify that their trusts meet requirements a) to f) above at the annual plan

stage and in each quarter. Failure to do so will result in the application of the service performance score for this indicator.n/a

Other

Failure against either threshold represents a failure against the overall target. The target will not apply to trusts having

five cases or fewer in a quarter. Monitor will not score trusts failing individual cancer thresholds but only reporting a single

patient breach over the quarter.

Failure against any threshold represents a failure against the overall target. The target will not apply to trusts having five

cases or less in a quarter. Monitor will not score trusts failing individual cancer thresholds but only reporting a single

patient breach over the quarter.

Failure against either threshold represents a failure against the overall target. The target will not apply to trusts having

five cases or less in a quarter. Monitor will not score trusts failing individual cancer thresholds but only reporting a single

patient breach over the quarter

Performance is measured on an aggregate (rather than specialty) basis and NHS foundation trusts are required to meet

the threshold on a monthly basis. Consequently, any failure in one month is considered to be a quarterly failure for the

purposes of the Compliance Framework. Failure in any month of a quarter following two quarters’ failure of the same

measure represents a third successive quarter failure and should be reported via the exception reporting process. Will

apply to consultant-led admitted, non-admitted and incomplete pathways provided. While failure against any threshold will

score 1.0, the overall impact will be capped at 2.0.

Healthcare Acquired Infections

Cancer Waiting Times (all indicators reported with a one month lag)

Referral to Treatment Waiting Times

Completeness - All records submitted.

Timeliness - All patients were submitted in time for

submission.

Audit - External Parkhill audit has taken place on

01/03/2012 with a rating of 'Adequate Assurance'.

Internal October 2013 data quality audit rated as 'Data

quality is above minimum requirements'.

Timeliness - Not all records are updated within 24

hours of activity.

Audit - Internal October 2013 audit rated as 'Data

quality is above minimum requirements'.

DQ Badge

Data Quality Badge

Timeliness

Source

Completeness

Granularity

Validation

Audit

Assessment of Executive Director

Not sufficient

Sufficient

Exemplary

Not yet assessed

Sufficient (Light Green) Not sufficient (Red)

Granularity ▪ Available at speciality level ▪ Directorate level

Timeliness ▪ Data entered within 24hours of activity, data

extract available daily

▪ Data not entered within 24 hours or extracts not available daily / unknown age

Completeness ▪ Not applicable to this item ▪ The lower of: >0% blanks or exceeded national tolerance

for data items used to calculate indicators

Final validation ▪ Final sign off by Ops Manager ▪ No signoff or sign off by data entry staff

Source ▪ Undocumented system or standardised and

mapped manual process

▪ Undocumented manual process

Audit ▪ Compliance for at least one local audit in the last 6

months, tabled at a group listed in the DQ Policy

▪ No audit tabled at a group listed in the DQ Policy within last 12 months or compliance not acceptable

Assessment of ED ▪ Exec Director would, on balance, vouch for

data quality being sufficient

▪ Exec Director cannot vouch for data

Exemplary (Dark Green)

▪ Always available at HRG and/or patient level

▪ Data entered realtime and available to access as of midnight previous day

▪ The lower of: 0% blanks or within national tolerance for data items used to calculate indicators

▪ Final sign off by Exec Director

▪ Fully documented system with audit control

▪ Consistent compliance for internal audit, tabled at a group listed in the DQ policy

▪ Exec Director would, on balance, vouch for data quality being exemplary

HSMR (to Nov-2013, Source: Dr Foster) & Crude Mortality Data (to Jan-2014, Source: PAS)

0

20

40

60

80

100

120

140

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

be

r

Oct

ob

er

No

vem

ber

Dec

emb

er

Jan

uar

y

Feb

ruar

y

Mar

ch

HSM

R

Month

01 HSMR: 2010/2011 to 2012/2014* by Month

2011/2012 2012/2013 National Average

2010/2011 2013/2014*

96.0

107.1

96.7

88.2

0.0

20.0

40.0

60.0

80.0

100.0

120.0

2010/2011 2011/2012 2012/2013 2013/2014*

HSM

R

Year

02 HSMR: 2010/2011 to 2013/2014* by Year

0

10

20

30

40

50

60

70

80

90

100

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

ber

Oct

ob

er

No

vem

ber

Dec

emb

er

Jan

uar

y

Feb

ruar

y

Mar

ch

Dea

ths

Month

03 Inpatient Deaths: 2010/2011 to 2013/2014* by Month

2010/2011 2011/2012 2012/2013 2013/2014*

1.3% 1.3% 1.3%

1.2%

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

2010/2011 2011/2012 2012/2013 2013/2014*

Mo

rtal

ity

Rat

e

Year

04 Crude Mortality Rate: 2010/2011 to 2013/2014* by Year

HSMR (to Nov-2013, Source: Dr Foster) & Crude Mortality Data (to Jan-2014, Source: PAS)

1.1%

2.0%

1.1%

2.4%

1.2%

2.1%

1.0%

2.1%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

Weekday Weekend

Mo

rtal

ity

Rat

e

Admission Day

07 Crude Mortality Rate: 2010/2011 to 2013/2014* by Admitting Day (Weekday vs Weekend)

2010/2011 2011/2012 2012/2013 2013/2014*

0

20

40

60

80

100

120

THHFT - Weekday London SHA Providers - Weekday

Provider Group

9 HSMR: 2010/2011 to 2013/2014* THHFT vs London Providers (Weekdays only)

2010/2011 2011/2012 2012/2013

2013/2014* National Average

0

20

40

60

80

100

120

140

THHFT - Weekend London SHA Providers - Weekend

Provider Group

10 HSMR: 2010/2011 to 2013/2014* THHFT vs London Providers (Weekends only)

2010/2011 2011/2012 2012/2013

2013/2014* National Average

NB THHFT HSMR for this category differs from all other categories due to application of Super Spell concept by Dr Foster. Specifically, if a Super Spell exists, the death is allocated to the first provider within the Super Spell

NB THHFT HSMR for this category differs from all other categories due to application of Super Spell concept by Dr Foster. Specifically, if a Super Spell exists, the death is allocated to the first provider within the Super Spell

Quality Dashboard: Feb-2014 (Final)

ID Indicator Source Performance in2012/2013

Performance in2013/2014 YTD

Target2013/2014

Apr-2013 May-2013 Jun-2013 Jul-2013 Aug-2013 Sep-2013 Oct-2013 Nov-2013 Dec-2013 Jan-2014 Feb-2014 Mar-2014

Clinical Effectiveness[01] Mortaility Indicators

a HSMR* (aggregate) 96.7 88.2 <100 111.4 76.2 82.6 85.3 99.5 78.8 89.8 88.3 75.9b HSMR* (aggregate) Upper & Lower Limits (89.6 - 104.18) (80.32 - 96.56) n/a (88.04 - 139.01) (54.88 - 102.94) (60.02 - 110.91) (62.92 - 113.16) (75.19 - 129.26) (55.75 - 108.15) (67.24 - 117.43) (66.53 - 114.96) (56.35 - 100.11)c HSMR* (weekday) 95.1 85.1 <100 106.0 58.6 87.3 77.3 100.7 79.8 81.3 93.2 76.4d HSMR* (weekday) Upper & Lower Limits (87.11 - 103.72) (76.28 - 94.72) n/a (80.29 - 137.37) (37.92 - 86.52) (60.45 - 122.01) (53.2 - 108.56) (73.14 - 135.15) (53.41 - 114.57) (56.29 - 113.6) (67.41 - 125.49) (54.03 - 104.82)e HSMR* (weekend) 102.9 96.3 <100 125.9 132.4 69.0 105.5 100.3 75.0 110.9 74.3 73.8f HSMR* (weekend) Upper & Lower Limits (88.45 - 119.13) (80.44 - 114.33) n/a (77.88 - 192.4) (77.06 - 211.92) (33.02 - 126.86) (59 - 174.01) (53.34 - 171.49) (34.22 - 142.38) (67.69 - 171.23) (39.5 - 126.98) (38.08 - 128.88)g SHMI 0.8878 0.9011 n/a 0.8984 n/a n/a 0.9063 n/a n/a 0.9011 n/a n/a 0.8835 n/a n/a

h SHMI Banding As Expected As Expected As Expected As Expected n/a n/a As Expected n/a n/a As Expected n/a n/a Lower ThanExpected

n/a n/a

[02] Crude Mortality (In-Hospital)a Deaths (Absolute) 786 624 n/a 83 42 47 51 64 42 52 59 59 81 44b Mortality Rate 1.32% 1.18% n/a 1.66% 0.80% 1.05% 1.0% 1.3% 0.9% 1.0% 1.3% 1.2% 1.5% 1.0%

[03] Palliative Care Coding*a THHFT Coding Rate 2.60% 3.07% tbc 3.35% 2.32% 3.36% 2.68% 4.20% 2.72% 3.54% 3.10% 2.45%b National Coding rate 2.67% 2.88% tbc 2.75% 2.89% 2.88% 2.93% 2.99% 3.07% 3.03% 2.84% 2.54%

Patient Safety[04] Hospital Acquired Infections

a MRSA 1 1 National: 0(de minimis: 6)

0 1 0 0 0 0 0 0 0 0 0

b MRSA cases per 100,000 beddays 0.7 0.8 n/a 0.0 8.5 0.0 0.0 0.00 0.00 0.00 0.00 0.00 0.00 0.00

c CDiff 23 12 National: 14(de minimis: 12)

0 2 0 1 2 1 2 1 2 0 1

d Cdiff cases per 100,000 beddays 16.2 9.4 n/a 0.0 17.1 0.0 9.0 18.2 9.0 16.9 9.0 16.6 0.0 8.4e E Coli 16 22 15 2 3 2 2 0 5 4 3 0 1 0f MSSA 5 4 4 1 0 0 1 0 1 0 0 0 0 1

[05] Rate of Patient Falls per 1,000 beddaysa All Falls 5.8 5.1 4.6 4.1 4.2 6.7 6.8 5.3 3.8 4.3 5.1 4.9 5.1 6.4b With Harm 1.6 1.5 tbc 1.2 1.3 1.7 2.0 2.0 0.9 1.5 1.3 1.5 1.5 1.4

[06] Patient Falls with Fracture 13 6 <12 / Annual<=1 / Month

0 0 0 3 0 0 1 0 0 0 2

[07] Medication Related Incidents per 100 beddays

0.2 0.3 tbc 0.3 0.2 0.3 0.3 0.2 0.3 0.3 0.2 0.2 0.2

[08] VTE Compliance PAS 91.9% 95.2% 95% 91.6% 95.5% 96.5% 96.6% 95.2% 95.9% 95.6% 95.4% 94.5% 95.8% Ava. 31Mar[09] VTE (Hospital Acquired) tbc[10] Attributable Pressure Ulcers

a Volume (Grade 2,3,4) 128 , 4 , 0 161, 5, 3 tbc 9 , 2, 0 14, 0, 0 15, 0, 0 14, 0 , 0 17, 0, 0 8, 0, 1 13, 0, 0 16, 0, 0 20, 0, 0 17, 3, 2 18, 0, 0

b Rate per 1,000 beddays 0.93 1.32 tbc 1.31 1.37 1.34 1.20 1.55 0.81 1.10 1.40 1.65 1.75 1.51

[11] Safety Thermometer (Harm Free Care)a All Harms ST Tool 93.4% 94.4% 95% 94.8% 92.4% 95.3% 94.9% 94.7% 94.1% 93.2% 94.1% 96.3% 93.8% 95.4%b New Harms ST Tool 96.6% 97.8% 95% 97.4% 98.5% 97.7% 97.3% 96.6% 98.9% 97.2% 97.3% 99.0% 96.9% 98.7%

[12] Patient Safety Incidentsa Total 5498 5409 tbc 488 457 457 561 494 444 471 471 456 558 552b Resulting in Harm 238 337 tbc 36 30 25 24 36 28 28 20 28 35 47

[13] Serious Incidents (SI Panel) 4 8 n/a 2 0 2 0 2 0 1 0 0 1 0[14] Never Events 1 2 0 0 1 1 0 0 0 0 0 0 0 0

Patient Experience[15] Same Sex Breaches

a Same Sex Breaches OperationsTeam

3 1 0 0 0 1 0 0 0 0 0 0 0 0

b Rate per 1,000 FCEs Derived 0.05 0.04 0 0 0 0.21 0 0 0 0 0 0 0 0[16] FFT Response Rates

a Accident & Emergency IWGC 8% 19.8% 15% 14.8% 12.8% 10.6% 16.1% 32.2% 23.3% 22.5% 19.8% 26.7% 27.1% 20.5%b Inpatients IWGC 23% 43.5% 30% 33.0% 39.7% 53.7% 44.0% 48.3% 51.8% 52.0% 45.3% 40.3% 36.5% 35.0%

[17] FFT - Net Promoter Scorea Accident & Emergency IWGC +57 +52 tbc +44 +41 +55 +53 +51 +51 +58 +53 +58 +61 +55b Inpatients IWGC +63 +65 tbc +62 +60 +64 +65 +68 +66 +64 +69 +66 +64 +64

[18] Overall Patient Experiencea Inpatients Meridien 88% 91% >=88% 87% 88% 88% 92% 92%b Outpatients Meridien 87% 87% >=88% 92% 88% 88% 85% 87% 85% 83% 87% 88% 88% 86%c Maternity Meridien 86% 86% >=87% 86% 84% 85% 87% 86% 85% 87%

[19] Complaintsa Volume (Plan Agreed) Datix 495 382 <40/month 39 40 58 29 27 31 35 30 24 34 35b Response Rate Datix 76.1% 72.1% >90% 78.4% 52.9% 56.1% 66.7% 92.6% 76.0% 89.3% 85.7% 55.3% 73.3% 86.1%

[20] Number of Negative PALS Concerns PALS(Datix)

786 681 n/a 55 63 95 60 51 43 80 58 44 47 85

* Dr Foster Basket of 56 Diagnosis groups

ClinicalGovernance

(STEIS)

Dr Foster

InfectionControl Team

ClinicalGovernance(Datix / iR)

HSCIC

PAS

Dr Foster

ClinicalGovernance(Datix / iR)

Measures of Infection Prevention and Control

February2014

Performance in 2012/13

February Performance

Year-to-Date Performance

2013/14Target

2013/14 traffic light

Clinical Support Services

Medicine Surgery Women & Childrens Comments

Mandatory Reporting1 MSSA blood stream infections (attributed to the Trust) 5 1 4 NT 1

2 E Coli blood stream infections (attributed to the Trust) 16 0 19 NT

Local Reporting3 Compliance with MRSA screening policy (elective) 111% 105% 98% 100%

4 Compliance with MRSA screening policy (non elective) 102% 106% 101% 100%

5 Number of needle stick injuries reported 73 5 71 NT 3 1 1

Local Monthly IP&C performance indicators6 Uptake of mandatory IP&C training (clinical level 2) 83% NA 86% >80% Data not available. Training for clinical staff now all in 1 level with annual refresher training.

7 Uptake of mandatory IP&C training (non clinical level 1) 86% NA 85% >80% Data not available. The trust has changed training frequency for non clinical from once to every 3 years. Staff currently have a training amnesty February and March.

8 Managerial Cleaning Audit - very high risk (VHR)* 91% 96% 94% >95% 97 96 94 98

9 Managerial Cleaning Audit high risk (HR)* 93% 95% 95% >92% 97 94 96 96

10 Compliance with restricted antibiotic policy 84% NA 88% >95% Move to quarterly restricted antibiotic reporting, data to be published March 14

11 Compliance with hand hygiene policy 98% 99% 98% >95% 100 99 100 100

12 Compliance with Bare Below Elbows 99% 100% 100% >95% 100 100 100 100

13 Contamination of Blood Cultures 3% 5% 4% NT

Monthly High Impact Interventions (HIIs)14 HII No. 1 - Central venous catheter care 99% 100% 100% >97% 100

15 HII No. 2 - Peripheral line care (VIP) 98% 97% 98% >97% 96 98 98

16 HII No. 5 - Ventilator care 99% 99% 98% >97% 99

17 HII No. 6 - Urethral catheter care 93% 84% 92% >95% 85 86 75 Poor documentation across the organisation -performance to be discussed at ICC

18 HII No. 7 - Clostridium difficile care bundle 91% NA 93% >95% 1 patient audited and results pending

19 New Quick Question Assessment - Environment NM 93% 94% >90% 100 92 87 89 Out of 74 separate measures 55 were compliant

20 HII No. 8 - New Quick Question Assessment - Clinical Equipment 84% 91% 88% >90% 97 93 90 94 Out of 74 separate measures 51 were compliant

Bi-annual / Annual IP&C local measures

21 Compliance with Isolation Policy 90% NM 80% >90%

22 Compliance to linen policy 93% NM NM >95% Audit to be completed in March

23 HII No. 4 - Preventing surgical site infection 85% NM 93% >85% Audit tool amended and waiting for final approval from audit

NM = not measured NA = not available NT = No Target IP&C RAG rating for compliance of 95% IP&C RAG rating for compliance of 90% Compliance >95% Compliance>90%Partial Compliance 70%-94%Minimal Compliance 0%-69%

Partial Compliance 70%-Minimal Compliance 0%-

Strategic Trend Analysis

Jan-13 Jan-14

Establishment 2794.38 2777.42

Bank Usage (wte) 149.57 196.42

Agency Usage (wte) 66.29 107.16

Permanent Staffing Levels 2273.79 2232.89

Fixed term Staffing Levels 306.62 312.35

Vacancy Rate (%) 7.66% 8.36%

Turnover Rate (%) 9.16% 10.11%

Sickness Rate (%) 3.89% 3.12%Note:

Increase in establishment is largely attributed to the transfer of cleaning and catering staff

PEOPLE DASHBOARD - Strategic

Main summary:

Sickness:

The overall sickness rate across the Trust for the month of January is more than the Trust target of 3%

The Trust's YTD sickness rate is more than the target rate of 3% and is 3.12%

The Following departments are currently exceeding the specified thresholds (3%):

Medicine Division Admin = 6.05% Surgical Wards = 4.20%

Critical Care = 5.73% Emergency Care = 4.18%

Women's Services = 4.77% People & Development = 3.97%

Outpatients THH = 4.73% Outpatients MVH = 3.96%

Radiology = 4.34% Theatres = 3.39%

Medical Wards = 4.25%

Medicine , Women's and Childrens and the Corporate Division have all exceeded the YTD

sickness target of 3% with the Women's and Childrens Division having the highest YTD

sickness rate at 4.29%

The estimated cost of sickness (YTD) is £ 1,980,440

Action Plan

Run additional training for managers in relation to managing sickness absence.

Provide additional support for managers in relation to managing sickness absence.

Spend Data:

Bank spend in Jan 2014 increased by 22%, whilst agency spend also increased by 52 %

compared to the previous month

At the end of Month 10, spend on Bank, Agency, Overtime, Waiting Lists and Additional Hours is already

£ 9,273,161 At this point last year the spend was £7,734,466 which represents an 16.59% increase in spend

for the same period year on year

The Division of Medicine currently has the highest YTD spend at £ 3,743,196

PDR & STaM:

PDR Doctors's Appraisals STaM

CSS 90.58% 45.45% 84.70%

Medicine 68.08% 54.24% 67.50%

Surgery 78.98% 54.88% 75.60%

W&C 85.84% 37.04% 82.50%

Corporate 88.48% 75.90%

Trust wide 83.87% 50.99% 76.30%

Trust Target 90.00% 100.00% 80.00%

Additional Comments:

In order to try and reduce the vacancy rate further, substantive recruitment plans will be agreed

with Directorates. Recruitment campaigns are ongoing for bank, with a view of increasing the

pool of staff available.

In order to get a better understanding of why staff are leaving, the P&D Department has

re-launched the exit interview process to improve the quality of data captured

The PDR process has been launched for 2013, for some bands this process has been revised to

include talent management. The deadline for completion this year is 30 Aug 2013.

Month Ending Jan 2014

Executive Summary

Recruited an Attendance Project Lead to work with Service Managers to help improve health and well-being, and

reduce levels of sickness absence

Overall sickness across the Trust has decreased, compared to the previous month (now 3.12%, was previously 3.24.%)

3.89%

3.12%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

Jan 2013 Jan 2014

Month 10 Sickness Comparison

£0

£500,000

£1,000,000

£1,500,000

£2,000,000

£2,500,000

£3,000,000

£3,500,000

£4,000,000

£4,500,000

Bank Agency Overtime Waiting List Additional WorkHours/Sessions

YTD Spend Comparison (Month 10)

Jan 2013

Jan 2014

Performance Negative Warning Positive Trust Target

Highlights

Comments

Absence returns were not received from 12 departments.

Please note that the Labour Turnover rate calculated on Permanent staff only

Area Funded establish.

(wte)

Permanent

(wte)

Fixed term

(wte)

Bank (wte) Agency (wte) Total Workforce

(wte)

% Temporary

Workforce

Vacancies

(wte)

Vacancies (%) Jobs

advertised

Time to recruit

(from Advert to

point of formal

offer) Avarege

DaysCSS 615.54 535.42 49.70 25.74 2.95 613.81 4.67% 30.42 4.94% 11.00 106.00

Medicine 627.73 485.62 99.21 88.53 43.41 716.76 18.41% 42.91 6.84% 40.00 52.00

Surgery 533.42 397.88 82.10 33.24 5.64 518.86 7.49% 53.44 10.02% 13.64 74.00

W&C 368.92 278.54 66.17 22.98 7.20 374.89 8.05% 24.21 6.56% 10.00 78.00

Corporate 607.34 535.43 15.18 25.93 47.96 624.50 11.83% 56.73 9.34% 6.00 0.00

Trust 2777.42 2232.89 312.35 196.42 107.16 2848.81 10.66% 232.19 8.36% 80.64 77.50

Trust Target 126.00 12.83 8.00%

Bank (£) Agency (£) Overtime (£) Waiting List

(£)

Additional

Work

Hours/Session

s (£)

Grand Sum

£513,111 £158,068 £35,740 £94,543 £47,339 £848,800.30

£1,972,853 £1,066,232 £119 £77,539 £626,455 £3,743,196.69

£656,154 £296,775 £19,179 £152,421 £601,636 £1,726,166.02

£631,562 £262,705 £0 £0 £52,912 £947,178.46

£401,911 £1,332,169 £263,241 £0 £10,500 £2,007,820.36

£4,175,590 £3,115,948 £318,279 £324,503 £1,338,842 £9,273,161.83

London Benchmarkn/a

Area

Medicine

Surgery

Corporate

W&C

Trust

Agency (£) Sickness Turnover

-4% 0%

Movement on previous month

TBC

2% 22%

n/a

Total % FTE that did not submit an absence return = 3.995% - this figure represents that 122 staff have not had absences recorded against them

n/a

CSS

PEOPLE DASHBOARD - Strategic Month Ending Jan 2014

Vacancies Bank (£)

% Change on previous month 52%

WORKFORCE RESOURCES

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%Vacancy Trend over last 24 months (%)

£0.00

£100,000.00

£200,000.00

£300,000.00

£400,000.00

£500,000.00

£600,000.00

Bank & Agency spend over 24 Month Period (£)

Agency

Bank

Year to date Previous

Financial Year

(2012/13)

Estimated

days

(1/4/2013 -

31/3/2014)

No. of staff

with 3

episodes in

last 6 months

No. of cases

with action

taken

No. of staff long term

sick leave (current

month)

No. of cases

with action

taken

CSS 3.08% 2.85% 8.76 9.98 10.51 £ 401,257 46 18 13 8 11

Medicine 3.48% 3.40% 10.28 14.67 12.34 £ 475,201 25 17 14 12 18

Surgery 2.83% 2.42% 7.67 11.01 9.20 £ 328,555 29 8 1 1 16

W&C 3.72% 4.29% 12.85 14.09 15.42 £ 352,627 24 24 15 15 4

Corporate 2.69% 3.24% 9.60 9.47 11.52 £ 422,801 31 17 10 10 8

Trust 3.12% 3.12% 9.67 11.73 11.60 £ 1,980,440 155 84 53 46 68Trust Target 3.00%

Current

month

Year to Date Previous

Financial Year

(2012/13)

Estimated

(1/4/2013 -

31/3/2014)

CSS 27 47 0.78% 7.36% 11.68% 8.83% 13.21% 10.58% 39.04%Medicine 47 77 0.76% 14.45% 11.81% 17.34% 16.73% 18.15% 10.95%Surgery 12 39 0.70% 8.94% 7.94% 10.73% 10.19% 10.71% 10.55%W&C 41 46 2.19% 14.47% 13.98% 17.36% 17.82% 15.31% 6.57%Corporate 54 46 0.79% 7.72% 11.68% 8.83% 17.82% 10.00% 4.58%Trust wide 181 255 0.94% 10.11% 10.79% 12.13% 14.67% 12.00%

Area No. of Grievances

raised (YTD)

No. of Dignity

at Work

Complaints

(YTD)

No. of

Disciplinary

Cases (YTD)

No. of

Capability

Cases (YTD)

Area Dismissal -

Capability

(YTD)

Dismissal - Conduct

(YTD)

Dismissal -

Some Other

Substantial

Reason

(YTD)

Dismissal -

Statutory reason

(YTD)

CSS 1 2 2 1 CSS 0 1 0 0

Medicine 1 1 15 0 Medicine 0 1 2 1

Surgery 0 1 2 0 Surgery 2 0 1 0

W&C 2 1 12 6 W&C 1 0 1 0

Corporate 5 1 10 0 Corporate 3 2 1 2Trust wide 9 6 41 7 Trust wide 6 4 5 3

Area % of PDRs

completed in

current PDR

cycle

(01/05/13 -

14/10/13)

%

Compliance

with STaM

Training

Doctors

Appraisal %

YTD

No. of

requests for

funding (does

not include

contracted

courses)

Safeguarding

Children Level 1

compliance %

Safeguarding

Vulnerable

Adults

compliance %

CSS 90.58% 84.70% 45.45% 10 77.30% 86.80%

Medicine 68.08% 67.50% 54.24% 4 52.20% 61.90%

Surgery 78.98% 75.60% 54.88% 0 63.80% 70.80%

W&C 85.84% 82.50% 37.04% 6 86.20% 87.90%

Corporate 88.48% 75.90% 0 85.40% 85.40%

Trust wide 83.87% 76.30% 50.99% 26 70.10% 77.10%Trust Target 90.00% 80.00% 100.00% 80.00% 80.00%

Notes/ Areas for Action1. Unless otherwise indicated, figures are as at current month end

2. % Temporary Workforce includes bank & agency staff only

3. Vacancies are calculated using funded establishment provided by Finance and ESR staff in-post figures

4. RAG rating for sickness: 2.7% and below = Green; between 2.71% and 3% = Amber; Greater than 3% = Red

5. Cost of sickness is calculated using salary cost per day, adjusted OMP/ OSP cost (other costs such as agency are not included)

6. Turnover figures are calculated using leavers during a period and whole time equivalent in post; figures exclude fixed term/ temporary staff

7. Estimated figures are based on financial year to date performance

8. RAG rating for PDR and Doctors Appraisals: 100% = Green, between 51% and 99% = Amber, below 50% = Red

9. RAG rating for STaM compliance (including: Safeguarding Children and Vulnerable Adults): 80% or above = Green, below 80% and greater than 40.01% = Amber, below 40% = Red.

10. Disciplinary information includes those disciplined for PIN lapse

STAFF EXPERIENCE AND DEVELOPMENT

TBCLondon Average

n/a

Area New starters

(Year to Date)

Leavers

(Year to

Date)

Labour Turnover (%) Nursing

Turnover (%)

Rolling 12

month

Turnover

(combined)

% of LeaversTop 5 reasons for leaving (Year to

Date)

Area % of working

days lost through

sickness

(Current)

Average Days Sickness% of working

days lost

through

sickness

(YTD)

Long Term Sickness

WORKFORCE PRODUCTIVITY

Estimated Cost

of sickness

(Year to date)

Short Term Sickness Staff on

maternity leave

End of Fixed Term

Retirement AgePromotionRelocationOther\Not Known

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

4.50%

Sickness Trend over last 24 months (%)

0.00%

5.00%

10.00%

15.00%

20.00%

Turnover Trend over last 24 months (%)


26 March 2014

THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST REPORT TO: Trust Board REPORT FROM: Paul Wratten, Finance Director DATE: 26th March 2014 SUBJECT: February 2014 (Month 11) Financial Report Trust Strategic Priority: • To deliver high quality care in the most efficient way. Summary: Attached is the full report and commentary covering the most recent financial performance (month 11) of the Foundation Trust to the end of February 2014. The Trust ended the period on plan with a cumulative deficit, after impairments, of £0.1m and with a continuity of services risk rating of 4. Earnings before Interest, Depreciation and Amortisation, EBITDA, was £13.4m, £0.5m ahead of plan and 7.2% of turnover. Actual efficiency savings achieved were £7.5m (4.3% of operating expenses) and £1.4m, 15.3% behind plan. Capital expenditure was £13.9m, £4.6m behind plan due to known slippage with the emergency care major scheme. Cash ended the month £1.2m ahead of plan at £6.2m with trade payables levels remaining significantly reduced. The Trust now forecasts it will achieve a better financial position at the year-end than its approved plan. It is set to deliver a modest non-recurrent surplus of around 0.5% of turnover that can be used to finance additional capital investment in 2014/15. This is a key performance report of the Trust’s statutory financial compliance obligations as a licensed provider of NHS commissioned services. Board Action Required: The Board is requested to: 1. Note the current and forecast financial performance of the Trust. 2. Discuss any further action required. Equality Impact Assessment: N/A –there is no positive or negative impact from this report.

FINANCIAL REPORT FOR

FEBRUARY 2014, QUARTER 4, 2013/14

EXECUTIVE SUMMARY

Financial performance for February 2014 was a surplus before impairments of £415k, £591k better than plan. After impairments the position was a deficit of £585k. Year-to-date the position was a surplus before impairments of £974k, £616k better than plan and after impairments a deficit of £85k. The Trust’s continuity of services risk rating remained at 4 (3.5). Slippage on the major capital scheme temporarily improved the Trust’s liquidity rating. This is expected to unwind in March to deliver the planned rating of 3 (3.0). Both revenue and operating expenses increased significantly during February 2014 reflecting the impact of the margins achieved from additional elective and emergency activity undertaken for North West London Hospitals NHS Trust and from the DH winter pressures investment. In addition, the Board should note a review of accruals and bad debt provisions was undertaken in preparation for the financial year-end and this yielded some additional unplanned non-recurrent financial gains. Although efficiency savings achieved to-date was behind plan at the end of the month, performance was £790k, £169k (27.2%) better than February last year. The Trust remains on course to achieve actual year-end efficiency savings of £8.3m, 4.4% of operating expenses. The Board should note the February report includes an estimated impairment to-date of £1m in relation to assets demolished as a part of the Emergency Care Scheme new build. A professional valuation has been organised to confirm the value prior to year-end and this will be reported along with other annual accounts issues to the April meeting of the Audit and Assurance Committee. KEY MESSAGES

• Year-to-date actual financial performance to February 2014 was a surplus before impairments of £974k, £616k better than plan. EBITDA was £13,392k, 7.2% of revenue and £476k ahead of plan.

• Total revenue was £2,342k ahead of plan for the month. NHS Clinical

Revenue was £2,047k ahead of plan for the month and £4,003k ahead of plan year-to-date. The Board should note the positive variance was generated from revenue outside of Hillingdon and other North West London commissioners.

1 | P a g e

• Non-NHS Clinical Income continued to reduce during February 2014 due to a reduction in Overseas Visitor income and ended the month just behind plan for the year-to-date.

• The over-achievement for the month and year-to-date on Other

Operating Revenue was primarily due to an unplanned increase in Education & Training income.

• Total operating expenses were £1,693k above plan, £634k due to pay,

and £35k drugs. Clinical Supplies and Other Operating Expenses were £9k and £1,015k respectively higher than plan in month. The increase reflected a combination of the additional activity undertaken for North West London Hospitals NHS Trust and winter capacity initiatives.

• Actual efficiency savings for February 2014 were £790k, £136k

(14.7%) behind annual plan. This was £5k higher than last month and £169k higher than February last year.

• Year-to-date to the end of February 2014 savings were £7,467k,

£1,354k (15.3%) behind plan.

• All Clinical Divisions reported adverse cumulative variances for the month with Trust wide savings schemes reported a positive variance.

DIVISIONAL FINANCES

• All Clinical Divisions, except Clinical Support Services continued to reported significant budget over spends year-to-date to the end of February 2014. Surgery and Clinical Support Services delivered in month under spends primarily due to increased activity for the month.

• Estates and Facilities also delivered an in-month under spend of £64k.

CASH AND BALANCES • The Trust ended the month with a £6.2m cash balance ahead of plan

by £1.2m whilst payables levels remained low. • The balance sheet reported a positive £5.1m net current asset

position. It is forecast this will reduce to £2.3m by the end of March 2014 and will further reduce in line with medium-term financial planning during the first quarter of 2014/15 due to the increased capital expenditure phased into those periods.

• Capital expenditure at £14.9m year-to-date and £2.8m for the month

remained significantly behind plan. As planned this was primarily linked with the Emergency Care major Scheme.

• The year-end capital expenditure forecast remains at £17.7m, which is

£1.9m behind plan.

2 | P a g e

OTHER KEY STRATEGIC POINTS • The total cost of discretionary pay, agency and bank staff was £437k

higher than plan for February and £663k higher than the year-to-date plan.

• The Board should note the opening of Edmunds Ward to service the additional activity for North West London Hospitals NHS Trust generated demand for extra non-substantive staff not anticipated in the agreed financial plan. Compared to average expenditure in the first eleven months of the financial year agency expenditure increased by £184k, primarily linked to A&E and other winter capacity initiatives and Edmunds Ward. Bank expenditure increased by £41k and discretionary pay increased by £93k.

• Births at 311 for the month were 3 lower than February last year. Year-to-date there were 145, 3.7% fewer births than last year.

• New GP outpatient referrals year-to-date were virtually the same as last year indicating commissioner QIPP plans were having some impact on demand to the Trust.

• A&E attendances remained stable at the post UCC 1 October 2013 level.

• Total emergency inpatient activity year-to-date decreased by 281, 1.1% compared to last year. The Board should note however, as there has been a significant reduction in short-term admissions to the Observation Ward, this position reflected a significantly increased acuity of patients being admitted.

• Year-to-date elective and day case activity reduced by 849, 3.7% compared to the end of February last financial year.

Equality Impact Assessment: N/A – there is no positive or negative impact from this report. Paul Wratten Finance Director March 2014

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Appendix A

Annual Yr on Yr Actual Actual Var Actual Var Year Yr on Yr Var 2014/15 2015/16Plan Growth to to-date Yr on Yr to-date This Yr on Yr This End Forecast to Forecast Forecast

Outturn Growth Month Growth Month Forecast Growth Plan£000s % £000s % £000s £000s % £000s £000s % £000s £000s £000s

Operating RevenueNHS Clinical Revenue 170,643 1.0% 161,175 4.2% 4,003 16,306 16.4% 2,047 177,227 4.9% 6,584 176,486 175,276Non-NHS Clinical Revenue 5,269 4.8% 4,751 2.9% (78) 364 1.1% (75) 5,303 5.4% 34 5,420 5,539Other Operating Revenue 21,282 3.7% 20,077 4.9% 563 2,144 12.0% 370 21,868 6.5% 586 22,220 22,534Total Operating Revenue and Income 197,194 1.4% 186,003 4.3% 4,488 18,814 15.5% 2,342 204,398 5.1% 7,204 204,126 203,349

Operating ExpensesEmployee Benefits (125,886) 0.4% (118,275) 3.3% (2,521) (11,255) 6.6% (634) (129,530) 3.3% (3,644) (130,525) (128,931)Drugs (12,500) 3.9% (12,013) 10.0% (488) (1,067) 5.9% (35) (13,059) 8.6% (559) (13,631) (14,094)Clinical Supplies (20,848) (0.2%) (19,063) (0.6%) 418 (1,795) 2.6% (9) (20,785) (0.5%) 63 (20,649) (20,153)Other Operating Expenses (24,046) (8.7%) (23,260) (1.9%) (1,421) (3,033) 15.6% (1,015) (25,650) (2.6%) (1,604) (25,139) (24,634)Total Operating Expenses (183,280) (0.7%) (172,611) 2.6% (4,012) (17,150) 7.6% (1,693) (189,024) 2.4% (5,744) (189,944) (187,812)

EBITDA 13,914 40.5% 13,392 33.2% 476 1,664 370.1% 649 15,374 55.2% 1,460 14,182 15,537

PFI & Lease Depreciation (1,263) 24.7% (1,227) 32.5% (93) (137) 73.4% (11) (1,285) 26.9% (22) (1,285) (1,285)Other Depreciation (6,991) 5.8% (6,082) (1.4%) 161 (662) 8.5% (74) (6,665) 0.9% 326 (7,059) (7,734)Interest Receivable 14 0.0% 16 23.1% 5 2 100.0% 1 17 21.4% 3 17 17Other Interest Payable (8) (88.7%) (62) 1.6% 4 (5) 0.0% 1 (68) (4.2%) (60) (68) (68)Interest Payable on Capital Investment Loans (284) 0.0% (246) (5.4%) 18 (23) 0.0% 1 (268) (5.6%) 16 (268) (268)Interest Payable on LIFT Contract (1,344) 0.0% (1,239) 0.6% (7) (100) (20.6%) 12 (1,364) 1.5% (20) (1,364) (1,364)Interest Payable on Other Finance Leases (205) 44.4% (169) 55.0% 18 (14) 27.3% 9 (180) 26.8% 25 (180) (180)PDC Dividend (3,761) 6.5% (3,409) 3.4% 34 (310) 3.3% 3 (3,719) 5.3% 42 (3,954) (4,378)Surplus(Deficit) before Impairments 72 - 974 - 616 415 - 591 1,842 - 1,770 21 277

Profit/(Loss) on the Disposal of Assets 0 33 - 33 0 - 0 33 - 33 0 0Impairments (185) (1,092) - (1,092) (1,000) - (1,000) (1,092) - (907) (8,121) 0

Surplus(Deficit) after Impairments (113) - (85) - (443) (585) - (409) 783 - 896 (8,100) 277

EBITDA % 7.1% 7.2% 10.6% 8.8% - 7.5% - 6.9% 7.6%Normalised Surplus (Deficit) % 0.0% 0.5% 13.7% 2.2% - 0.9% - 0.0% 0.1%

( ) variance indicates it is adverse

THE HILLINGDON HOSPITALS NHS FOUNDATION TRUSTRevenue StatementPeriod Ending 28th February 2014 (Month 11)

Appendix BIncome and Expenditure Trend Analysis

15,000

15,500

16,000

16,500

17,000

17,500

18,000

18,500

19,000

Jan FebMar AprMayJun Jul AugSep Oct NovDec Jan FebMar AprMay

£000

s

Income Trend Analysis January 2011 to May 2014

Last Year This Year Trend

14,500

15,000

15,500

16,000

16,500

17,000

17,500

JanFebMar AprMayJun Jul AugSepOctNovDecJanFebMar AprMay

£000

s

Operating Expenses Trend Analysis January 2011 to May 2014

Last Year This Year Trend

-2000

200400600800

1,0001,2001,4001,6001,800

Jan Feb Mar Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar Apr May

£000

s

EBITDA Trend Analysis January 2011 to May 2014

Last Year This Year

-500

-400

-300

-200

-100

0

100

200

300

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

£000

s

Surplus/(Deficit) Against Plan April 2013 to March 2014

Plan Actual

Appendix C THE HILLINGDON HOSPITALS NHS FOUNDATION TRUSTDivisional Performance Summary Period Ending 28th February 2014 (Month 11)

Annual Plan Actual Variance Variance Year-End Risk WTE's WTE's WTE's ChangePlan Last Month Forecast to Substantive Other Total from

To-Date To-Date To-Date Variance Achieving Last£000's £000's £000's £000's % £000's £000's Target Month

Clinical Support Services (25,226) (23,126) (22,827) 299 (1.3%) (15) 0 Low 564 34 598 4Medicine and Emergency Care (33,805) (31,059) (32,856) (1,797) 5.8% (1,534) (1,970) High 569 134 703 (3)Surgery (41,399) (37,991) (38,325) (334) 0.9% (372) (375) Medium 479 59 538 7Women & Children (18,706) (17,164) (17,890) (726) 4.2% (644) (750) Medium 329 41 370 8Estates and Facilities & Corporate Devt. (19,023) (17,443) (17,617) (174) 1.0% (236) (220) Medium 339 60 399 (2)Finance and Information (6,495) (5,935) (5,726) 209 (3.5%) (7) 0 Low 104 8 112 (1)Corporate Nursing (1,801) (1,651) (1,645) 6 (0.4%) 8 0 Low 27 0 27 (2)Senior Management (1,711) (1,577) (1,561) 16 (1.0%) 13 20 Low 13 0 13 (2)Human Resources (1,782) (1,633) (1,608) 25 (1.5%) 9 0 Low 36 7 43 1Education Centre (282) (258) (226) 32 (12.4%) 38 50 Low 9 0 9 0Director of Operations (2,315) (2,119) (2,064) 55 (2.6%) 40 20 Low 31 1 32 (1)Other Corporate and Reserves 152,617 140,314 143,319 3,005 (2.1%) 2,725 4,203 Low 11 0 11 (3)

Total 72 358 974 616 172.1% 25 978 Medium 2,511 344 2,855 6

Efficiency Savings Delivery by DivisionPeriod Ending 28th February 2014 (Month 11)

Last Year Plan Plan Actual Variance Variance Year-End Worst BestActual For Year To-Date To-Date To-Date Last Month Forecast Case Case£000's £000's £000's £000's £000's % £000's £000's £000's £000's

Clinical Support Services 1,297 1,667 1,517 1,406 (111) (7.3%) (179) 1,558 1,514 1,567Medicine and Emergency Care 1,527 2,338 2,091 1,292 (799) (38.2%) (684) 1,354 1,345 1,354Surgery 1,358 1,620 1,463 1,091 (372) (25.4%) (330) 1,216 1,190 1,273Women & Children 389 864 789 661 (128) (16.2%) (118) 727 692 744Estates and Facilities & Corporate Devt. 914 1,403 1,270 1,051 (219) (17.2%) (161) 1,248 1,069 1,323Finance and Information 183 296 271 332 61 22.5% 64 364 316 457Corporate Nursing 35 111 99 31 (68) (68.7%) (61) 35 29 37Human Resources 84 130 118 65 (53) (44.9%) (48) 72 72 82Director of Operations 34 151 139 115 (24) (17.3%) (27) 131 115 136Trustwide Savings 526 1,162 1,064 1,423 359 33.7% 326 1,562 1,504 1,634Total 6,347 9,742 8,821 7,467 (1,354) (15.3%) (1,218) 8,267 7,846 8,607

Appendix DEfficiency Savings Delivery by ProgrammePeriod Ending 28th February 2014 (Month 11)

Plan for the

Year

Plan To-Date

Actual To-

Date

Variance To-Date

Year-End Forecast

Worst Case

Best Case

Efficiency Saving Project £000's £000's £000's £000's % £000's £000's £000'sOutpatient Productivity 356 312 323 11 3.5% 367 334 384Improving Inpatient Care 1,492 1,336 620 (716) (53.6%) 619 617 619Theatre Productivity 374 327 148 (179) (54.7%) 179 173 186Medical Rota Efficiency 592 537 243 (294) (54.7%) 264 258 291Job Planning 58 56 51 (5) (8.9%) 51 51 51Nursing Rota Efficiency 1,318 1,175 803 (372) (31.7%) 860 806 887Clinical Support Workforce 226 205 90 (115) (56.1%) 95 95 95Non-Clinical Support Workforce 615 561 411 (150) (26.7%) 476 442 493Diagnostics, Consumables and Prescriptions Review 1,453 1,338 1,582 244 18.2% 1,755 1,739 1,814Procurement 2,245 2,068 2,139 71 3.4% 2,320 2,142 2,364Pay and Remuneration 577 514 427 (87) (16.9%) 470 453 519Utilisation of Assets and Estates 523 473 630 157 33.2% 811 736 904Contingency (87) (81) 0 81 100.0% 0 0 0Total 9,742 8,821 7,467 (1,354) (15.3%) 8,267 7,846 8,607

Appendix E THE HILLINGDON HOSPITALS NHS FOUNDATION TRUSTAnalysis of Operating ExpensesPeriod Ending 28th February 2014 (Month 11)

Last Annual Budget Actual Var Actual Year 20014/15Year Plan To-date To-date To-date Yr on Yr End Year-End

Actual Growth Forecast Forecast£000s £000s £000s £000s £000s % £000s £000s

PayMedical Staffing - Non-Training Grades (22,240) (22,221) (20,433) (20,899) (466) 2.8% (22,920) (23,150)Medical Staffing - Training Grades (12,700) (12,115) (11,140) (12,214) (1,074) 4.9% (13,490) (13,550)Nurses & Midwives (36,991) (36,407) (33,477) (34,361) (884) 1.4% (37,680) (37,625)Scientific, Therapeutic & Technical Staff (9,671) (10,112) (9,298) (9,342) (44) 5.4% (10,200) (10,375)Other Clinical Staff (19,497) (19,279) (17,727) (17,956) (229) 2.0% (19,590) (19,925)Non-Clinical Staff (24,286) (25,752) (23,679) (23,503) 176 6.0% (25,650) (25,900)Total Pay Costs (125,385) (125,886) (115,754) (118,275) (2,521) 3.3% (129,530) (130,525)

To note on PayAgency Staff (2,120) (3,143) (2,890) (3,646) (756) 35.3% (4,000) (3,750)Bank Staff (5,055) (5,055) (4,648) (4,690) (42) 2.4% (5,125) (5,100)Discretionary Pay (2,827) (2,827) (2,599) (2,464) 135 (6.6%) (2,700) (2,000)Total (10,002) (11,025) (10,137) (10,800) (663) 8.9% (11,825) (10,850)

Non-PayClinical Supplies & Services (32,925) (33,348) (31,006) (31,076) (70) 3.2% (33,844) (34,280)General Supplies & Sevices (2,839) (2,593) (2,355) (2,951) (596) 5.1% (3,220) (3,290)Establishment (3,917) (3,578) (3,250) (3,825) (575) 5.3% (4,175) (4,265)Premises and Fixed Plant (8,250) (7,536) (6,844) (5,911) 933 (22.6%) (6,460) (6,590)Ambulance Services (1,047) (956) (869) (875) (6) (8.6%) (970) (980)Other Non-Pay (10,272) (9,383) (8,521) (9,698) (1,177) 11.7% (10,825) (10,014)Total Non-Pay Costs (59,250) (57,394) (52,845) (54,336) (1,491) 1.0% (59,494) (59,419)

Total Expenses (184,635) (183,280) (168,599) (172,611) (4,012) 2.6% (189,024) (189,944)

Appendix FTHE HILLINGDON HOSPITALS NHS FOUNDATION TRUSTThirteen Month Rolling Cashflow Report & Forecast

Monthly Analysis 2013/14 2013/14 2013/14 2012/13 2013/14 2013/14 2013/14 2013/14 2013/14 2013/14 2013/14 2013/14 2014/15 2014/15 2014/15 2014/15 2014/15 2013/14April May June July August September October November December January February March April May June July August Full Year

Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

Opening Cash 3,906 2,147 1,185 2,817 4,764 6,049 4,826 3,562 3,582 6,631 7,215 6,244 3,387 2,918 2,597 1,761 1,761 3,906

ReceiptsHealthcare Contracts 12,295 12,330 12,330 18,186 12,745 13,513 13,466 13,782 13,650 13,647 13,511 13,600 13,600 13,600 13,600 13,600 13,600 163,055Other NHS 4,071 3,498 2,978 2,968 1,208 2,730 3,365 3,097 4,307 4,231 2,543 1,800 2,673 2,673 1,144 1,144 1,144 36,796Commercial 650 1,074 1,596 362 700 581 320 1,499 1,103 1,001 722 1,400 900 900 1000 1,000 1,000 11,008PDC Dividend Receipt 0 0 0 2,350 2,030 1,700 1,300 1,430 808 1,199 154 234 0 0 0 0 0 11,205

PaymentsSalaries & Wages (6,073) (6,048) (5,974) (5,925) (6,040) (5,967) (6,033) (5,964) (5,960) (5,997) (6,188) (6,150) (6,150) (6,150) (6,100) (6,100) (6,100) (72,319)Tax, N.I. & Pensions (4,334) (4,335) (4,334) (4,623) (4,394) (4,302) (4,329) (4,337) (4,369) (4,370) (4,330) (4,300) (4,450) (4,450) (4,450) (4,450) (4,450) (52,357)Other Expenses (7,618) (6,771) (2,942) (10,341) (3,734) (6,431) (8,023) (8,295) (5,760) (7,147) (5,903) (4,595) (5,000) (4,852) (4,800) (4,800) (4,800) (77,560)Dividend Payable 0 0 0 0 0 (1,798) 0 0 0 0 0 (1,881) 0 0 0 0 0 (3,679)LIFT and Lease Payments (200) (210) (216) (230) (230) (230) (230) (230) (230) (230) (230) (230) (230) (230) (230) (230) (230) (2,696)Capital Payments (550) (500) (1,806) (800) (1,000) (687) (1,100) (962) (500) (1,750) (1,250) (2,400) (1,812) (1,812) (1,000) (1,000) (1,000) (13,305)Loans Repayments 0 0 0 0 0 (332) 0 0 0 0 0 (335) 0 0 0 0 0 (667)

Closing Cash 2,147 1,185 2,817 4,764 6,049 4,826 3,562 3,582 6,631 7,215 6,244 3,387 2,918 2,597 1,761 925 925 3,387

Weekly AnalysisWeek Comm

Week Comm Week Comm

Week Comm

Week Comm

Week Comm

Week Comm

Week Comm

Week Comm

Week Comm

Week Comm

Week Comm

Week Comm

13 Week Rolling Forecast 1/2/14 8/2/14 15/2/14 22/2/14 1/3/14 8/3/14 15/3/14 22/3/14 29/3/14 5/4/14 12/4/14 19/4/14 26/4/14Opening Cash 7,215 5,775 4,305 13,070 6,244 5,874 5,304 9,722 3,387 2,567 2,190 10,022 9,402

ReceiptsHealthcare Contracts 0 0 13,511 0 0 0 13,600 0 0 0 13,600 0 0Other NHS 600 600 800 543 500 300 300 700 0 243 1,200 650 580Commercial 0 300 200 222 200 200 500 500 0 250 250 250 150Dividend Receipt 0 0 154 0 0 0 234 0 0 0 0 0 0Drawdown of Loans

PaymentsSalaries & Wages (80) (70) (70) (5,968) (70) (70) (70) (5,940) (70) (70) (70) (70) (5,870)Tax, N.I. & Pensions 0 0 (4,330) 0 0 0 (4,300) 0 0 0 (4,450) 0 0Other Expenses (1,960) (1,800) (1,000) (1,143) (1,000) (1,000) (1,000) (1,595) (750) (800) (656) (1,450) (1,344)Dividend Payable 0 0 0 0 0 0 (1,881) 0 0 0 0 0 0Lease Payments 0 0 0 (230) 0 0 (230) 0 0 0 (230) 0 0Capital Expenditure 0 (500) (500) (250) 0 0 (2,400) 0 0 0 (1,812) 0 0Loans Repayments 0 0 0 0 0 0 (335) 0 0 0 0 0 0

Closing Cash 5,775 4,305 13,070 6,244 5,874 5,304 9,722 3,387 2,567 2,190 10,022 9,402 2,918

Creditor Stretch b/f (1,962) (2) 587 376 (292) (503) (714) (925) (541) (1,602) (2,013) (2,568) (2,329)Expenditure (1,211) (1,211) (1,811) (1,211) (1,211) (1,211) (1,211) (1,811) (1,211) (1,211) (1,211) (1,211)Payments 1,960 1,800 1,000 1,143 1,000 1,000 1,000 1,595 750 800 656 1,450 1,344Creditor Stretch c/f (2) 587 376 (292) (503) (714) (925) (541) (1,602) (2,013) (2,568) (2,329) (2,196)

Period Ending 28th February 2014 (Month 11)

Appendix GTHE HILLINGDON HOSPITALS NHS FOUNDATION TRUSTStatement of Financial Position Period Ending 28th February 2014 (Month 11)

31-Mar-13 28-Feb-14 Movement 31-Mar-14 31-Mar-15Actual Actual Actual Forecast Forecast£000's £000's £000's £000's £000's

Non-Current AssetsIntangible Assets 1,948 1,501 (447) 1,568 1,568Plant, Property and Equipment (Owned) 101,330 106,043 4,713 109,092 108,518Plant, Property and Equipment (Leased) 13,587 14,816 1,229 14,848 14,062Investment Property 14,816 14,816 0 14,816 14,816Trade and other receivables 1,473 1,408 (65) 1,391 1,391

Total Non-Current Assets 133,154 138,584 5,430 141,715 140,355

Current AssetsInventories 3,042 3,032 (10) 2,988 2,988NHS Trade Receivables 6,484 7,610 1,126 7,615 5,615PDC Dividend Receivable 65 0 (65) 0 0Non-NHS Trade Receivables 1,051 385 (666) 811 811Prepayments and Accrued Income 5,400 13,023 7,623 8,477 8,477Cash and Cash Equivalents 3,906 6,244 2,338 3,387 3,547

Total Current Assets 19,948 30,294 10,346 23,278 21,438Total Assets 153,102 168,878 15,776 164,993 161,793Current Liabilities

Trade Payables 4,306 2,871 (1,434) 2,260 6,768Capital Payables and Accruals 580 827 247 2,786 1,786Other Payables 5,646 5,104 (542) 5,277 5,277Accruals and Deferred Income 8,141 11,791 3,650 6,876 6,876PDC Dividend Payable 0 1,546 1,546 0 0Provisions 165 162 (3) 162 162Other Liabilities 1,454 1,541 87 1,780 1,780BorrowingCapital Investment Loans 390 390 0 390 390LIFT 258 258 0 258 258Finance Leases 705 705 0 1,177 1,177

Net Current Assets/(Liabilities) (1,697) 5,099 6,795 2,312 (3,036)Total Assets Less Current Liabilities 131,457 143,683 12,225 144,027 137,319

Non-Current Liabilities (amounts falling due after more than one year)Provisions 1,948 2,250 302 2,378 2,378BorrowingCapital Investment Loans 7,075 6,880 (195) 6,685 6,295LIFT 12,877 12,660 (217) 12,642 12,384Finance Leases 1,990 3,439 1,449 2,767 2,040

Total Assets Employed 107,567 118,454 10,886 119,555 114,222

Taxpayers EquityPublic Dividend Capital 60,251 71,222 10,971 71,456 71,456Retained Earnings 24,226 24,142 (85) 25,709 18,309Revaluation Reserve 23,090 23,090 0 22,390 24,457

Total Taxpayers' Equity 107,567 118,454 10,886 119,555 114,222

Appendix H THE HILLINGDON HOSPITALS NHS FOUNDATION TRUSTCash Flow StatementPeriod Ending 28th February 2014 (Month 11)

41670 31-Mar-14 31-Mar-15Actual Forecast Forecast£000's £000's £000's

EBITDA after non-operating revenue/costs 13,392 15,374 14,182Excluding Non-Cash I&E Items:- 0 (80) 0Disposal of spinal equipment 17 17 0Movement in Working Capital:Inventories 10 54 0NHS Trade Receivables (1,126) (1,131) 2,000PDC Dividends Receivable 65 65 0Non-NHS Trade Receivables 666 240 0Other Receivables (7,623) (3,077) 0Trade Payables (1,434) (2,046) 4,508Capital Payables and accruals 247 2,206 (1,000)Other Payables 4,654 (1,634) 0Provisions 299 427 0Other Liabilities 87 326 0Cash Flow from Operations 9,254 10,741 19,690Capital ExpenditureCapital Expenditure (13,913) (17,702) (12,238)Cash Receipt from Asset Sales 0 0 0Cash Flow before Financing (4,659) (6,961) 7,452Movement in Long-Term Payables 0 0 0Movement in Long-Term Receivables 65 82 0InterestInterest Paid on Capital Investment Loans (308) (336) (336)Interest Paid on LIFT Contract (1,239) (1,364) (1,364)Interest Paid on Finance Leases (169) (180) (180)Interest Received on Cash Balance 16 17 17Loans and LeasesRepayment of Capital Investment Loans (195) (390) (390)Repayment of LIFT Contract (217) (235) (258)Additional funding by Finance Leases 2,456 1,500 2,638Repayment of Finance Lease Capital (1,007) (138) (3,465)OtherPublic Dividend Capital Received 10,971 11,205 0Public Dividend Capital Repaid 0 0 0Proceeds on the Disposal of Assets 33 0 0Dividends Paid (3,409) (3,719) (3,954)Net cash (Outflow)/Inflow 2,338 (519) 160

Opening Cash Balance 3,906 3,906 3,387

Closing Cash Balance 6,244 3,387 3,547

Appendix ITHE HILLINGDON HOSPITALS NHS FOUNDATION TRUSTCapital Expenditure ReportPeriod Ending 28th February 2014 (Month 11)

2013/14 Actual Plan Variance Year-End Year-EndPlan To-Date To-Date To-Date Forecast Variance

£000s £000s £000s £000s £000s £000s

Major Medical Equipment - Outright Purchase 1,100 639 1,012 (373) 1,100 0Information Management Technology - Outright Purchase 1,500 1,414 1,826 (412) 1,500 0Estates - Outright Purchase 3,200 2,423 2,996 (573) 3,200 0Emergency Care Scheme - PDC Funded 9,000 4,973 8,536 (3,563) 7,270 (1,730)Maternity - PDC Funded 741 744 741 3 744 3Major Medical Equipment - New Lease Funded 500 0 0 0 0 (500)Information Management Technology - New Lease Funded 2,000 1,046 2,500 (1,454) 1,046 (954)Major Medical Equipment - Replacement New Lease Funded 1,013 1,410 924 486 1,500 487Dementia Care - PDC Funded 0 828 0 828 845 845Contingency 500 436 0 436 497 (3)

Total 19,554 13,913 18,535 (4,622) 17,702 (1,852)

Appendix JTHE HILLINGDON HOSPITALS NHS FOUNDATION TRUSTFinancial Risk Management ReportPeriod Ending 28th February 2014 (Month 11)

Worst Current LikelyCase Likely Impact£000s Incidence £000s Notes

Risks to Financial Plan

Non-delivery of efficiency savings 1,896 0.78 1,475 Based on likely outcomeNon-achievement of CQUIN 550 0.10 55 From planned 65% to achievement of 50%Contract penalties 1,000 0.20 200 Overall risk but mainly CdiffNon-payment of contract overperformance 3,400 0.05 170 Overall 2% activity growthNon-HCCG growth & local repatriation 625 0.10 63 Impact of not achieving additional contributionActivity related cost reductions 900 0.25 224 Impact of not achieving required savingsAdditional Winter cost pressures 1,200 1.00 1,200 In addition to planned amountNon-Pay inflation 450 0.10 45 1% higher than 2.5% built in the Annual Plan

Value of Financial Risks 10,021 3,432

Mitigating Actions

Use of annual plan contingency 1,000 1.00 1,000 Incorporated into the Annual PlanContract penalty contingency 1,000 1.00 1,000 Incorporated into the Annual PlanDelay new quality investment 1,500 0.00 0 Potential remainder after all commitmentsPotential Winter pressures funding 1,200 1.00 1,200 Based on previous years bidsRevenue impact of capital slippage 167 0.00 0 Forecast balance after all current commitmentsBalance sheet flexibilities 1,000 1.00 1,000 Current available downside mitigations

Value of Mitigating Actions 5,867 4,200

Residual Risk 4,154 - (768)

Normalised I&E surplus (deficit) as a result of residual risk 768

Continuity of Services Risk Rating 3

Appendix K

Continuity of Service Risk Rating and Other Financial Performance Metrics

Period Ending 28th February 2014 (Month 11)

Continuity of Service Risk RatingMetric

n/a n/a Capital Service Planning 2.0 3 2.0 3 2.4 3 1.4 2n/a n/a Liquidity (9.9) 2 3.6 4 (0.8) 3 (6.7) 3

Weighted Average 2.5 3.5 3.0 2.5

Overriding Rules Impact 3 4 3 3

Other Ratio's20 Receivables Days 13 16 17 1317 Payable Days 22 18 14 42

1.0 Current Ratio 1.2 1.2 1.1 0.9

Forecast Rating Forecast Rating


12/13 13/14 13/14 To-Date 13/14 14/15Actual Rating Plan Rating Actual Rating

Appendix L

Annual Financial

Plan

Financial Plan

Actual Var Var Actual Contract Plan

Actual Actual Contract Plan



Actual Actual Actual Actual

YTD YTD Yr onYr YTD YTD Yr onYr YTD YTD Yr onYr YTD YTD Yr onYr YTD YTD Yr onYr Yr onYrGrowth Growth Growth Growth Growth Growth

£000's £000's % % £000's £000's % £000's £000's % £000's £000's % £000's £000's % £000's %

Inpatients

Daycase (Spells) 16,754 15,359 15,438 79 1% -6% 11,197 11,214 -11% 1,745 1,836 -3% 457 455 22% 1,675 1,734 21% 199 44%Elective (Spells) 11,631 10,690 11,067 377 4% -4% 7,656 8,212 -4% 1,523 1,400 0% 46 67 5% 1,247 1,217 -9% 171 -9%Non-Elective (Spells) 47,504 43,325 45,146 1,820 4% -4% 34,861 36,059 -3% 6,389 5,833 -3% 316 688 -27% 893 1,121 0% 1,445 -4%

Total Inpatients 75,889 69,374 71,651 2,276 3% -4% 53,714 55,484 1% 9,658 9,069 9% 820 1,210 -12% 3,815 4,072 54% 1,815 129%

Outpatients

New (Attendance) 10,352 9,657 10,712 1,055 11% -8% 7,020 8,100 -15% 1,255 1,231 -9% 46 99 n/a 1,040 1,129 72% 152 64%Follow Up ( Attendance) 12,307 11,620 12,196 576 5% 7% 9,017 9,326 2% 1,042 1,632 13% 74 134 n/a 892 956 24% 148 32%Procedure (Attendance) 9,033 8,279 9,602 1,323 16% 11% 6,046 7,172 6% 936 906 -15% 14 35 n/a 1,128 1,323 69% 167 145%Ward Attender 578 530 443 -87 -16% -31% 444 363 -31% 57 55 -40% 2 5 n/a 16 17 -12% 3 6%Outpatient Unbundled 3,153 2,889 1,988 -901 -31% n/a 2,349 1,440 n/a 370 207 n/a 0 0 n/a 116 115 n/a 227 n/aMaternity Ante/Postnatal 8,646 7,987 7,801 -186 -2% 2% 6,729 6,279 -4% 1,158 1,307 39% 0 0 n/a 0 119 -18% 97 35%

Total Outpatients 44,070 40,963 42,743 1,780 4% 7% 31,605 32,680 1% 4,818 5,337 9% 136 273 n/a 3,192 3,659 54% 794 129%

A&E (Attendance) 8,587 7,903 9,240 1,337 17% -10% 5,483 6,693 -10% 1,555 1,322 -13% 0 0 n/a 829 770 -7% 455 5%

Total A&E 8,587 7,903 9,240 1,337 17% -10% 5,483 6,693 -10% 1,555 1,322 -13% 0 0 n/a 829 770 -7% 455 5%

Critical Care (bed days) 6,742 6,274 6,415 141 2% -3% 2,912 3,227 4% 642 442 -28% 2,419 2,145 -11% 129 98 -27% 502 36%Rehab - Specialist & Non specialist (bed days) 3,725 3,409 3,643 234 7% 10% 2,341 2,550 13% 972 948 2% 0 0 n/a 32 114 37% 32 -10%Chemotherapy (spells) 653 599 574 -25 -4% -7% 13 0 n/a 1 0 n/a 578 574 n/a 7 0 n/a 0 n/aDirect Access (tests) 5,917 5,415 5,609 194 4% 9% 4,861 5,125 11% 344 339 -10% 0 0 n/a 108 133 17% 13 -37%Excluded Drugs & Anti VEGF 6,931 6,354 6,858 504 8% 15% 402 1,051 28% 128 126 -10% 4,897 2,772 29% 360 0 2,909 1%Block and other clinical income 7,173 6,575 7,549 974 15% 5% 1,366 1,317 -24% 158 158 -1% 2,552 2,831 1% 0 667 52% 2,576 28%Other Non-Central Income - - 535 535 n/a n/a - - - - - - - - - - - - 535 n/aTransitional Funding/Marginal Rate 8,000 7,598 1,767 -5,832 n/a n/a 6,938 1,767 n/a - - - - - - - - - - -Northwick Park SLA - - 1,417 1,417 n/a n/a - - - - - - - - - - - - 1,417 n/aWinter pressures funding - - 769 769 n/a n/a - - - - - - - - - - - - 769 n/aCQUIN 2,954 2,708 2,405 -303 n/a n/a 1,662 1,744 n/a 295 287 n/a 106 73 n/a 132 258 n/a 44 n/a

Total Other Clinical Income 42,096 38,932 37,541 -1,391 -4% 20% 20,495 16,780 20% 2,540 2,301 -9% 10,553 8,395 4% 767 1,269 31% 8,796 55%

Total Clinical Income 170,643 157,172 161,175 4,003 3% 4% 111,297 111,638 -1% 18,571 18,028 -1% 11,509 9,878 5% 8,602 9,770 21% 11,861 42%

Contract Variance 341 -543 -1,631 1,168 4,667

THE HILLINGDON HOSPITALS NHS FOUNDATION TRUSTCONTRACT INCOME

Period Ending 31 February 2014 (Month 11)

Trust Position Hillingdon CCG Other North West London Specialised Other Contracts NCA's

Appendix M

Activity Plan

Activity Plan

Actual Var Actual Activity Plan

Actual Actual Activity Plan



Actual Actual Actual Actual

YTD YTD Yr onYr YTD YTD Yr onYr YTD YTD Yr onYr YTD YTD Yr onYr YTD YTD Yr onYr YTD Yr onYrGrowth Growth Growth Growth Growth Growth

% % % % % %Inpatients

Daycase (Spells) 20,992 19,241 18,458 (783) -5% 14,124 13,760 -10% 2,075 2,052 -7% 598 527 10% 1,868 1,905 45% 214 44%Elective (Spells) 3,535 3,215 3,301 86 2% 2,397 2,592 3% 400 371 -1% 14 19 -17% 30 275 -5% 44 2%Non-Elective (Spells) 25,897 23,621 25,917 2,296 -8% 18,481 20,459 -8% 3,373 3,405 -11% 200 351 -19% 815 681 -12% 1,021 3%

Total Inpatients 50,424 46,077 47,676 1,599 -6% 35,003 36,811 -8% 5,848 5,828 -9% 811 897 -4% 2,713 2,861 21% 1,279 8%

Outpatients

New (Attendance) 76,003 70,130 84,420 14,290 10% 51,024 64,183 3% 8,977 10,088 12% 196 393 n/a 7,703 8,527 77% 1,229 87%Follow Up ( Attendance) 178,192 164,878 188,387 23,509 13% 125,647 149,745 10% 20,584 22,869 22% 728 1,217 n/a 12,251 12,541 23% 2,015 42%Procedure (Attendance) 50,521 46,296 55,556 9,260 25% 33,570 41,345 17% 5,431 5,755 7% 57 145 n/a 5,882 7,240 110% 1,071 202%Ward Attender 8,116 7,437 5,620 (1,817) -23% 6,309 4,812 -24% 702 571 -20% 11 24 n/a 168 182 -6% 31 55%Outpatient Unbundled 28,154 25,799 16,075 (9,724) n/a 26,104 13,137 n/a 4,106 1,789 n/a - 0 n/a 1,286 1,011 n/a 138 n/aMaternity Ante/Postnatal 8,369 7,617 7,997 380 n/a 6,661 6,390 n/a 824 1,329 n/a - 0 n/a - 145 n/a 133 n/a

Total Outpatients 349,355 322,159 358,055 35,896 0% 249,316 279,612 -4% 40,624 42,401 -2% 992 1,779 n/a 27,290 29,646 42% 4,617 58%

A&E (Attendance) 76,420 71,607 87,170 15,563 -14% 43,669 60,645 -15% 15,257 12,737 -15% - 0 n/a 10,801 9,684 -9% 4,104 3%

Total A&E 76,420 71,607 87,170 15,563 -14% 43,669 60,645 -15% 15,257 12,737 -15% 0 0 n/a 10,801 9,684 -9% 4,104 3%

Critical Care 7,375 7,365 6,728 (637) -10% 2,269 2,376 -3% 457 300 -38% 4,456 3,634 -12% 93 73 -38% 345 30%Specialist Rehab 9,783 8,952 12,494 3,542 14% 5,962 9,198 17% 2,669 2,869 9% - 0 n/a 88 337 1% 90 -7%Chemotherapy 880 806 899 93 31% 13 0 n/a 1 0 n/a 735 899 31% 55 0 n/a 0 n/aDirect Access 1,102,676 1,009,511 998,369 (11,142) 0% 933,541 952,489 4% 33,990 40,573 -48% - 0 n/a 4,129 4,816 -6% 491 -28%

Total Other 1,120,714 1,026,635 1,018,490 (8,145) -1% 941,786 964,063 3% 37,116 43,742 -46% 5,192 4,533 -6% 4,366 5,226 -6% 926 -11%

Total 1,596,914 1,466,477 1,511,391 44,914 -2% 1,269,774 1,341,131 0% 98,846 104,708 -46% 6,995 7,209 25% 45,169 47,417 20% 10,926 20%

NCA's

THE HILLINGDON HOSPITALS NHS FOUNDATION TRUSTCONTRACT ACTIVITY

Period Ending 31 February 2014 (Month 11)

Trust Position Hillingdon CCG Other North West London Specialised Other Contracts

Appendix N

Activity Trend Analysis

5,5006,0006,5007,0007,5008,0008,5009,0009,500

10,00010,500

Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May

Spel

ls/ A

ttend

ance

s

A&E Activity March 2012 to May 2014

This year Last Year Trend

5,0005,2005,4005,6005,8006,0006,2006,4006,6006,8007,000


Spel

ls/ A

ttend

ance

s

All New Outpatient Referrals March 2012 to May 2014


1,7001,8001,9002,0002,1002,2002,3002,4002,5002,6002,7002,800


Spel

ls

Inpatient Activity March 2012 to May 2014

Elective This year Emergency This yearElective Last Year Emergency Last Year

290300310320330340350360370380390400


Birt

hs

Births March 2012 to May 2014



26th March 2014

THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST REPORT TO: Trust Board REPORT FROM: Simal Patel, Associate Director of Programme

Management REPORT SPONSORED BY: Karl Munslow Ong, Chief Operating Officer DATE: 26th March 2013 SUBJECT: Month 11 QIPP update Trust Strategic Priority: • To deliver high quality care in the most efficient way. Summary: At M11 the QIPP programme achieved £812k against a revised M11 plan of £866k resulting in a negative variance of £54k in month. YTD the savings delivered are £7.48m against a revised plan of £7.80m resulting in a negative variance of £313k. The year-end position is forecasted to be £8.2m. 2014/15 planning is well underway, £7m of schemes have been identified with plans, £850k have been identified with plans currently being worked up, and £1.1m of close the gap ideas have been identified to be developed. An initial risk assessment of the valuations and start dates has been carried our prior to schemes being entered into the database, a further scheme by scheme risk assessment will be carried out in the coming week. This may reduce the value but alongside this divisions are also working up additional schemes. The aim of the risk assessment is to identify ways in which to mitigate any slippage to schemes due to start in the early part of the year. Some divisions have really struggled to identify schemes due to the nature of the division e.g. CCSS where demand is largely driven by other divisions. In this case areas have been asked to carry out efficiency and productivity analysis to benchmark the way in which they work when compared to other Trusts to identify opportunities to same money or mitigate cost against service developments. Next steps include ensuring that strong plans are in place to deliver the schemes and identifying additional work streams to militate against any slippage or non-delivery. Board Action Required: The Board is asked to review the report and agree any further actions as required.

- 1 -

Month 11 QIPP update

1. Month 11 Performance Overview The table below shows the month on month plan vs actual delivery. The revised plan for M11 was £866k, an increase from M10 plan of £26k; actual delivery for the month was £812k which has resulted in a negative variance in month of £54k and an YTD variance of -£313k. As outlined below, the plan figures were profiled to achieve an outturn position of £8.7m, the actuals and the forecast for M11 and 12 demonstrate that the forecast outturn for 13/14 is likely to be £8.2m. The table below outlines the planned vs actual delivery month on month, this also includes the M12 forecast:

*M5 - 12 Plan outlined in the table is the risk adjusted plan which projects a forecast of £8.7m The graph below shows 13/14 plan against 12/13 actuals and 13/14 actuals.

Actual delivery has increased from £785k at M10 to £812k at M11. This is primarily due to a catch up value on the CCSS Hounslow pathology scheme. 2. 14/15 Transformation Programme savings target As previously outlined, the planning for 14/15 schemes has been underway since November. The financial target has been based on 5%/6% (clinical/non-clinical) of the current budgets and may change following the budget setting process. The savings target for 14/15 is £9m.

M1 M2 M3 M4 M5* M6* M7* M8* M9* M10* M11* Total Forecast M12*

Total

Plan* £400,325 £588,015 £731,720 £745,498 £650,000 £675,000 £720,000 £785,000 £800,000 £840,000 £866,000 £7,801,558 £866,000 £8,667,558Actuals £415,682 £524,704 £706,622 £649,362 £623,485 £683,114 £836,164 £731,664 £720,975 £784,920 £811,984 £7,488,676 £720,975 £8,209,651Variance £15,357 -£63,311 -£25,098 -£96,136 -£26,515 £8,114 £116,164 -£53,336 -£79,025 -£55,080 -£54,016 -£312,882 -£145,025 -£457,907

- 2 -

Divisional target – has been set at 5%

Surgery Medicine W&C CCSS

Divisional targets £2,086,187 £1,854,407 £1,008,124 £1,780,224 January target (2%) £834,475 £741,763 £403,250 £712,090 February target (4%) £1,668,950 £1,483,526 £806,499 £1,424,179 March (5%/6%) £2,086,187 £1,854,407 £1,008,124 £1,780,224

Corporate target – has been set at 6%

3. 14/15 Transformation Programme plans The table below summarises the plans in place against the 14/15 target. The overall target for 2014/15 is £9m of which £6.7m is set against the clinical divisions (5% of budget), £2.3m is the target for corporate areas (6% of budget). As outlined in the M10 Board paper, a large proportion of savings next year and in future years will need to come from larger transformation schemes, this year £3.6m has been identified against larger Trust-wide schemes. It is not anticipated that clinical divisions working in silos can identify their full 5%, section 5 shows the attribution of the Trust-wide schemes towards the divisional targets. Category £ (PYE) Target 9,000,000 Clinical Divisions Target 6,728,942 Carry forward value 583,764 Schemes with plans 3,053,185 Schemes with plans to be developed 300,000 Total identified 3,936,949 Gap 2,791,993 Corporate Divisions Target 2,279,922 Carry forward value 344,038 Schemes with plans 1,018,822 Schemes with plans to be developed 550,000 Total identified 1,912,860 Gap 367,062 Trust-wide schemes (Yr 1) 3,635,680 Net off double counts -1,635,000 Total 2,000,680 TOTAL IDENTIFIED with plans 7,000,489

Estates Facilities Corporate Dev

Dir of Nur HR Finance Dir of Ops CEO's office

Divisional targets £520,000 £780,000 £96,714 £110,962 £142,985 £399,062 £135,337 £101,743January target (2%) £173,333 £260,000 £32,238 £36,987 £47,662 £133,021 £45,112 £33,914February target (4%) £346,667 £520,000 £64,476 £73,974 £95,324 £266,041 £90,225 £67,828March (5%/6%) £520,000 £780,000 £96,714 £110,962 £142,985 £399,062 £135,337 £101,743

- 3 -

TOTAL IDENTIFIED with plans to be developed

850,000

Ideas which require further validation 1,100,000 Total 8,950,489 Gap 49,511 The total identified to date is £8.9m, a large proportion of this value is supported by delivery plans. The value also takes into account the planned start date. The valuations still require a risk assessment to be carried out, an informal assessment and scrutiny of the value (based on testing the assumptions behind the start date and the work-up of the valuation) has been carried out prior to any figures being added to the tracker. A scheme by scheme risk assessment will be carried out over the next week, this will also inform any immediate mitigating actions which need to be taken. The overall year 1 value for the Trust-wide schemes has been planned at £3.6m but an assessment of the divisional schemes has led to the identification of £1.6m of double counts between the saving areas identified within the divisions and those identified by the Trust-wide schemes. This £1.6m has been netted off the total value. The main aim over the next two weeks is to ensure that schemes that are due to start in April have robust delivery plans and also Divisions continue to identify further schemes in order to mitigate any reduction as a result of risk adjustments. 4. Trust-wide schemes The table below summarises the year 1 and 3 year savings against each of the Trust-wide schemes. The 3 year value does not necessarily equate to the full value of the opportunity, but illustrates that there are further opportunities that can be realised through the schemes over multiple years. The values for years 2 and 3 need to be worked up in more detail in order to show the full 3 year potential of the schemes. Trust-wide scheme Year 1 £ 3 Year £* 7 day services and IIC 1,350,000 1,850,000 Internal referral management 100,000 200,000 Building a sustainable and safer nursing workforce 312,204 412,204 Mount Vernon – maximising the use of the TC and MB 600,000 600,000 Reducing reliance on temporary staffing 623,476 723,476 Procurement 500,000 750,000 Accessible and Responsive services 150,000 400,000

Integrated Care 0 tbc TOTAL 3,635,680 4,935,680

*This 3 year value requires further work-up, it is anticipated that this value will be greater for most Trust-wide scheme areas and specifically around the integrated care agenda.

- 4 -

Trust-wide schemes apportioned by division shown below Trust-wide scheme

Surgery (£)

Medicine (£)

W&C (£)

CSS (£)

E&F (£)

7 day services and IIC

134,000 575,000 641,000 -

Internal referral management

35,000 35,000 15,000 15,000

Building a sustainable and safer nursing workforce

36,067 213,501 59,351 3,258

Mount Vernon – maximising the use of the TC and MB

600,000 - - -

Reducing reliance on temporary staffing

186,663 378,932 29,350 17,453 11,078

Procurement 250,000 80,000 100,000 70,000 Accessible and Responsive services

50,000 40,000 25,000 35,000

Integrated Care - - - - TOTAL 1,287,730 1,322,433 869,701 140,711 11,078 5. Clinical divisional breakdown (including Trust-wide schemes apportioned) The tables below outline the savings identified by division, these include the divisional apportionment of the Trust-wide schemes. The division with the greatest gap is CCSS where a large proportion of their activity is driven by demand from the other divisions. The internal referral management savings will ultimately fall out of CCSS but have been factored across the other divisions as they are cross-charged for their usage. CCSS are carrying out reviews in all areas which include benchmarking with other Trusts to identify further opportunities. Surgery Category £ (PYE) Target 2,086,187 Carry forward value 298,887 Schemes identified 717,555 Schemes with plans to be developed 100,000 Trust-wide scheme proportion 1,287,730 Net off double counts -434,000 Total 1,970172 Gap 116,015

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Medicine Category £ (PYE) Target 1,854,407 Carry forward value 142,000 Schemes identified 1,221,704 Schemes with plans to be developed 90,000 Trust-wide scheme proportion 1,322,433 Net off double counts -550,000 Total 2,221,704 Gap (367,297) CCSS Category £ (PYE) Target 1,780,224 Carry forward value 96,726 Schemes identified 495,093 Schemes with plans to be developed 80,000 Trust-wide scheme proportion 140,711 Net off double counts 0 Total 812,530 Gap 967,694 Women’s and Children’s Category £ (PYE) Target 1,008,124 Carry forward value 46,151 Schemes identified 618,833 Schemes with plans to be developed 30,000 Trust-wide scheme proportion 869,701 Net off double counts -651,000 Total 913,685 Gap 94,439 6. Monitoring and Tracking The transformation programme will be tracked weekly/fortnightly by the PMO through transformation divisional meetings or Trust-wide project steering board meetings. These meetings will be used to monitor progress against plan and track milestones on the project’s critical path. This will allow a risk assessment to be carried out which will identify any risks to delivery. The process in place is very similar to that followed this year. 7. Clinical Assurance Panel (CAP) and Quality Impact Assessments (QIA) The Quality Impact Assessment guidance has been updated following lessons learnt from last year, the QIA has also been updated following feedback from the CAP and divisions.

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For each scheme a project initiation document is completed, within this document the initial quality assessment is carried out. A full QIA is required if any of the following are true:

• The scheme is a Trust-wide scheme • There is a risk score against 1 or more risks of 10 or greater than 10 within

the PID quality assessment • The PMO have identified that there is a greater risk identified against the

scheme when considered in parallel to other schemes • The Divisional leadership team are unable to collectively sign-off the scheme.

The QIAs are then reviewed by the Clinical Assurance Panel (CAP) Chair and brought to CAP for discussion. In order to ensure that all schemes go through the CAP process prior to starting, the frequency of the CAP meetings from March have increased to fortnightly moving to weekly. The Clinical Assurance Panel provide clinical approval of the scheme or recommend further action to allow the scheme to progress. In some instances the schemes are rejected. This is tracked and reviews of specific schemes are requested by the panel at relevant points. 8. Tracking and identifying interdependencies between all change

programmes This year it has become essential to begin to link all change programmes as there are a number of interdependencies between them which need to be understood in the tracking and also in assessing the return on investment and any risks. A plan for linking and alignment of tracking of these programmes is being developed with a view to being able to review progress against all change programmes in a monthly/quarterly assessment. This will include service developments, CCG QIPP schemes and IT schemes. 9. Next Steps Over the coming two weeks all schemes will be reviewed in detail by the PMO which will include the project initiation document and the detailed plans to ensure that there is enough work-up to support delivery from the planned dates. A risk assessment will also be carried out against each scheme. Divisions with the support of the PMO are working up detailed plans and carrying out all the pre-work that needs to happen to support scheme delivery. Schemes are in varying stages but the main focus over the next couple of weeks will be on those that are due to start delivering from April. The divisions are also working through ideas that were previously generated but have not been developed into a plan to validate if these are appropriate to be taken forward.

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Exploring new ideas

Further scheme ideas are continually being reviewed through review of other Trusts’ programmes or investigating ideas such as outsourcing options. Exploration and work up of new ideas will continue through the year to support any schemes which fail to deliver and mitigate against other risks. Visits to other Trusts have also taken place to identify schemes which we may not have considered or to provide a level of challenge around the ambition of some of our schemes, this has already informed some of our plans to date. 10. CCG QIPP Monthly meetings have now been revised with the CCG to proactively review their QIPP schemes and understand the assumptions behind them in order to support any local planning that needs to happen. Current separate CCG QIPP monitoring systems are also being revised and a joint CCG/THH dashboard will be set-up which tracks CCG QIPP delivery and also key quality metrics which may be impacted by the change. The Planned QIPP schemes also have two weekly reviews internally by the Trust to help manage pace and timeline expectations. Summary of proposed CCG QIPP schemes for 14/15 QIPP Scheme name (from QIPP plan) Sum of QIPP

Activity 2014_15 GROSS

Sum of QIPP Cost 2014_15 GROSS (£)

Gastro Pathway Development -338 -47,492 Ophthalmology Pathway Re-Design -6,560 -579,480 Dermatology -4,129 -427,269 Urology -2,010 -565,767 ENT -4,258 -434,164 Cardiology -2,861 -452,960 MSK Pathway Development -204 -840,253 THH - Diagnostics (PC - LTC) - Pathology

-2,500 -10,854

Ambulatory Care -1,158 -1,732,099 Falls -43 -240,973 PCI -5,144 -634,174 A&E/UCC/WIC service developments: A&E to UCC

-32,737 -3,203,636

Gynaecology -6,806 -1,119,772 Respiratory PC -101 -271,418 ICP Pathway -101 -218,778 Expert Patient Programme (Diabetes & Asthma)

-102 -195,431

End of Life -73 -298,804 Care home Support -77 -151,573 THH - Diagnostics (PC - LTC) - Radiology

-2,000 -73,521

Excess Bed Days -2,054 -533,619 One Stop Hernia -214 -27,975 Pain Management (PC) -1,389 -219,990 Diabetic Medicine -592 -97,275 Neurology - Headaches -478 -117,846 Admission Avoidance (Phase 1, Part 2) - Rapid Response / Zero LOS

-3,000 -2,392,146

-78,930 -14,887,270

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Most of the unplanned schemes associated with admission avoidance are a continuation from 13/14. The CCG have plans to augment the expert patient programme and increase health promotion especially with long term conditions in particular COPD and diabetes. As previously mentioned THH are reviewing some of the schemes with the CCG to clarify their assumptions especially around reduction of excess bed days, care home support, end of life and Ambulatory care. All Planned care schemes except Dermatology from 13/14 will have full year effect in 14/15. There are two additional planned care schemes neurology (headaches) and one stop hernia, and clinical working groups are already up and running .

- 9 -


26 March 2014


REPORT TO: Trust Board REPORT FROM: Richard Grocott-Mason, Medical Director REPORT PRESENTED BY: Abbas Khakoo, Medical Director DATE: 26th March 2014 SUBJECT: Revalidation of Medical Staff: progress report Trust Strategic Priority: • To create a patient centred organisation to deliver improvements in patient

experience and the quality of care we provide. Summary: On 25th October 2013 the Trust received a report that outlined the Trust’s progress with the embedding of the revalidation process. This report therefore provides the Board with a six month update and provides assurance that The Hillingdon Hospitals NHS FT and the Responsible Officer are executing their duties in respect of Revalidation. Board Action Required: The Board is asked to: 1. Note the report and the assurance that the Trust is meeting the

requirements of revalidation. 2. Note the recent Organisational Readiness Self-Assessment (ORSA)

report. 3. Recognise the actions achieved to date and to approve an updated action

plan to improve the documented appraisal rates.

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Revalidation of medical staff: Progress report 1. Purpose of progress paper To provide Board with assurance that The Hillingdon Hospitals NHS FT and the Responsible Officer are executing their duties in respect of Revalidation. 2. Background Medical Revalidation was introduced in the UK on 3rd December 2012 and has been in place at the Trust for one year. On this date the Trust assumed a formal role in the regulation of doctors by becoming a ‘designated body’ with some specific legal requirements. Revalidation is the process by which the General Medical Council (GMC) confirms that a doctor’s licence to practice will continue. Its purpose is to assure patients and the public, employers and other healthcare professionals that licensed doctors are up to date and fit to practice. 3. Revalidation to date Dr Richard Grocott-Mason is the current Responsible Officer (RO) and Dr Robin Kantor is the Deputy Responsible Officer.

There are 239 doctors for whom we are currently the designated body. Each doctor has been allocated a date for revalidation by the GMC over the next 5 years. There are 42 trained Appraisers. The Trust plans to provide more Equiniti training to increase the number of appraisers in the Trust. There are four trained case investigators - three consultants and one SAS Doctor. The annual appraisal process is now electronic. The Trust provides doctors with an electronic system for annual appraisal (Equiniti 360). This allows each doctor to collect their portfolio of supporting information, as recommended by the GMC Good Medical Practice Guide. It also administers and analyses 360 degree feedback from colleagues and patients. This has to be provided at least once in every five year revalidation cycle by each doctor. Initially this system was only available for Consultants and permanent staff but is will be extended to all those for whom the Trust is the designated body. The Trust is working hard to ensure that all staff are on the Equiniti Revalidation Management System. We were awarded £5,000 from the Revalidation Support Team to facilitate training sessions to support revalidation in non-Consultant grade doctors. Approximately 40 Associate Specialist Doctors attended this training to increase their understanding of the appraisal and revalidation process and its importance.

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Regular Webinar sessions are run by our revalidation management provider (Equiniti RMS) to ensure all doctors understand how to use the system for the appraisal and revalidation processes. 4. Recommendations to GMC

To date the RO has made 40 positive recommendations, 4 requests for deferral and no notifications of non-engagement. We have three further doctors due to revalidate in March 2014.

5. Organisational Readiness Self-Assessment (ORSA) report

The Trust was written to on 25th October 2013 by NHS England to confirm the progress update for the 2013 – 2014 ORSA action plans. At the time, it was reported by NHS England that the Trust achieved an appraisal rate for 2012 / 2013 of 26.50 %. The ORSA results relate to 2012/13, and are therefore a snapshot of the position as at 31 March 2013 last year. We are working hard to ensure all doctors whose designated body is Hillingdon are put onto the revalidation management system (RMS) when they commence with the Trust. They are continually reminded of the importance of being appraised every year to meet their requirements for Revalidation and those set out by the GMC. We will continue to ensure that we maintain an accurate record of all doctors that we have a prescribed connection with in order to track all appraisals using the Equiniti Revalidation Management system. All doctors are given access to Equiniti upon commencement with the Trust. We have put in place an action plan to continue monitoring around this. It was confirmed in our response that we present information to the Board every six months. To date our documented rate of completed appraisals for our medical staff is 51.18% and will work hard to continue to improve this rate. The national results of all NHS organisations show that only 75.1% of consultants and 60.7% of staff grade and associate specialist doctors in the acute hospital sector had an appraisal in 2012/13. This compares with 84.3% and 80.7% respectively in mental health and 90.3% of GPs. Appraisal rates for doctors on short term contracts in NHS hospital trusts were 32.9%. 6. Summary The process of Medical Revalidation has been successfully introduced at THH FT and we continue to work hard to ensure that all doctors are using the Equiniti Revalidation management system and undertaking the 360 assessment. This has been helped by the strong clinical governance structures in place, and the Board’s emphasis on high quality care. The areas for improvement in the future are the documentation of completed appraisals, and the quality of medical appraisals, supporting information, linkage of data to individual clinicians and further strengthening recruitment processes.

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ORSA Action Plan March 2014

Action

Progress Lead Target Date Achieved

1. Reskilling, rehabilitation and retraining policy

Completed. Approved by Sept JLNC Minor editing required and to be put on Intranet

SF/RGM Sept 2013 Action point achieved

2 Training sessions for SAS doctors 3 dates organised – first session held 12 attendees RST support grant £5,000

SF/RGM 14th Sept 2013 Action point achieved

3 Revalidation & Appraisal Guidance circulated to all doctors

Complete RGM June 2013 Action point achieved

4 Ensure that all doctors have access to Equiniti system

Funding agreed – Sept 2013 SF liaising with Equinti to implement

SF/RGM Oct 2013 March 2014

5 Appointment of Medical Appraisal Leads Dr Shuba Vashist and Dr Jeya Anandanesan appointed

RGM July 2013 Action point achieved

6 Establish regular appraisal meetings for Appraisers Date for first meeting set up SF/RGM 30th Sept 2013

7 Identify and train more case investigators Next training Oct and Nov RGM Nov 2013 Action point achieved – 3 consultants / one SAS doctor have been trained in this.

8 Identify and train more Appraisers in the Trust Arranging sessions with Equiniti once funding has been identified for this. Quotes have been received

RGM/SF May 2014

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and doctors have put themselves forward for this training.

10 To increase and improve the appraisal rates within each division and across the Trust

Appraisal rates are reported to the Board on a monthly basis on progress with improving rates and through the Divisional People Dashboards

RGM/SF Monthly

11 To address areas of non-engagement with the appraisal process.

To set up a meeting to discuss the reasons why there has been non-engagement and what steps will be in place to ensure the appraisal occurs.

RGM/SF Appraisal leads

April 2014

SF – Siobhan Ferguson (Revalidation Lead HR) RGM – Richard Grocott-Mason (Responsible Officer)

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ITEM 18



REPORT TO: Trust Board REPORT FROM: Helen Cobb, Assistant Director Corporate

Governance REPORT SPONSORED BY: David Searle, Executive Director of Corporate

Development DATE: 26th March 2014 SUBJECT: Information Governance Standards 2013/14

Toolkit Assessment Process Trust Strategic Priority: • To create a patient centred organisation to deliver improvements in patient

experience and the quality of care we provide. Summary: The Information Governance compliance scores must be electronically submitted to NHS Connecting for Health (part of the Department of Health) by the 31st March 2014, and it is a requirement that the Trust Board formally approves the final submission. The Care Quality Commission and the National Information Governance Board also receive the results of the submission. This report sets out the final scoring based on the self-assessment process and the evidence submitted. The results have been approved by the Information Governance Steering Group on the 7th March 2014. Board Action Required: The Board is asked to approve the attached report containing the scores that will be submitted to NHS Connecting for Health. Appendices: Appendix A - Requirement scores Equality Impact Assessment: There is no positive or negative impact from this report.

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Information Governance Toolkit Version 11

Final submission report 1. Introduction

Information Governance (IG) provides a framework to bring together all the legal rules, guidance and best practice that apply to the handling of confidential information. The IG Toolkit is an evidence-based self-assessment which provides assurances that the Trust is complaint with IG standards and the information held is appropriately protected. This report sets out the scoring for the Information Governance Toolkit (IGT) v.11 Assessment. See Appendix A for scoring details.

2. Peer Review During March 2014 a Peer Review of the IGT requirements took place to

validate the evidence provided and to confirm the requirements as complete prior to the final submission at the end of March 2014.

3. Scoring

The Trust score for the final assessment submission is 81%, this is shown as ‘unsatisfactory’ because one of the 43 requirements relevant to this Trust is not at Level 2 (21 requirements are at level 3 and the remaining 21 are at level 2; level 0 being the lowest attainment level and 3 being the highest attainment level).

4. Gap The requirement currently at Level 1 is:

11-112 - Information Governance training programme Attainment of Level 1 for this requirement has been achieved and means that the Trust has a training programme in place; a training needs analysis has been undertaken and IG training is given at induction. To attain level 2, 95% of all staff must have completed or be in the process of completing annual IG training by March 2014 (this exceeds the current Trust target for statutory/mandatory training of 80%); a training needs analysis completed to ensure this training is sufficient and additional training taken up by those in key roles. The latter two parts of this level 2 requirement have been achieved. As of 12th March 2014, 1127 people have been trained in the face-to-face sessions (this includes corporate induction, classroom sessions, bespoke training for the in-house cleaning and catering staff and clinical audit days); 432 have completed training online and the newly launched refresher quiz has returned around 750 responses. The latest Statutory and Mandatory training report shows IG training running at 70% (12/03/14); this includes all temporary staff the figure without temporary staff would be 80%. A final drive has taken place during the remaining weeks of March to see if the training compliance figures can be pushed further towards the 95% goal, a verbal update on the training figures will be provided at the Board meeting.

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There is also some work to sift out the ‘active’ temporary staff (those who have worked this year) in order to work out a truer figure for the total staff numbers and to target these staff members for IG training.

5. Independent assessment This year there was no requirement for the IG toolkit to undergo an Internal

Audit. However the Information Governance Steering Group have asked that an Internal Audit is carried out next year to ensure our standards are maintained and assured. The Board should be aware that the IG toolkit requirements have not changed materially from last year, so the work required this year has been to upload this year’s evidence and provide monitoring evidence for the level 3 attainment levels.

6. Monitoring compliance and implications of non-compliance

There are no financial penalties in the Commissioning contract and the Trust has a plan in place to achieve level 2 going forward.

Compliance against the IG Toolkit no longer features in the Annual Plan Board statements under Monitor’s Risk Assessment Framework 2013/14.

7. Board Action Required The Board is asked to approve this Information Governance Toolkit submission to Connecting for Health. Helen Cobb Assistant Director, Corporate Governance March 2014

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APPENDIX A

INFORMATION GOVERNANCE TOOLKIT v.11 FINAL ASSESSMENT REPORT – MARCH 2014

Req No

Description Attainment Level

Information Governance Management 11-101

There is an adequate Information Governance Management Framework to support the current and evolving Information Governance agenda

3

11-105

There are approved and comprehensive Information Governance Policies with associated strategies and/or improvement plans

3

11-110

Formal contractual arrangements that include compliance with information governance requirements, are in place with all contractors and support organisations

2

11-111

Employment contracts which include compliance with information governance standards are in place for all individuals carrying out work on behalf of the organisation

2

11-112

Information Governance awareness and mandatory training procedures are in place and all staff are appropriately trained

1

Confidentiality and Data Protection Assurance 11-200

The Information Governance agenda is supported by adequate confidentiality and data protection skills, knowledge and experience which meet the organisation’s assessed needs

3

11-201

Staff are provided with clear guidance on keeping personal information secure and on respecting the confidentiality of service users

2

11-202

Personal information is only used in ways that do not directly contribute to the delivery of care services where there is a lawful basis to do so and objections to the disclosure of confidential personal information are appropriately respected

2

11-203

Individuals are informed about the proposed uses of their personal information

2

11-205

There are appropriate procedures for recognising and responding to individuals’ requests for access to their personal data

3

11-206

There are appropriate confidentiality audit procedures to monitor access to confidential personal information

3

11-207

Where required, protocols governing the routine sharing of personal information have been agreed with other organisations

2

11-209

All person identifiable data processed outside of the UK complies with the Data Protection Act 1998 and Department of Health guidelines

Not Relevant

11-210

All new processes, services, information systems, and other relevant information assets are developed and implemented in a secure and structured manner, and comply with IG security accreditation, information quality and confidentiality and data protection requirements

2

Information Security Assurance 11-300

The Information Governance agenda is supported by adequate information security skills, knowledge and

2

4


Req No


experience which meet the organisation’s assessed needs 11-301

A formal information security risk assessment and management programme for key Information Assets has been documented, implemented and reviewed

3

11-302

There are documented information security incident / event reporting and management procedures that are accessible to all staff

2

11-303

There are established business processes and procedures that satisfy the organisation’s obligations as a Registration Authority

2

11-304

Monitoring and enforcement processes are in place to ensure NHS national application Smartcard users comply with the terms and conditions of use

2

11-305

Operating and application information systems (under the organisation’s control) support appropriate access control functionality and documented and managed access rights are in place for all users of these systems

2

11-307

An effectively supported Senior Information Risk Owner takes ownership of the organisation’s information risk policy and information risk management strategy

3

11-308

All transfers of hardcopy and digital person identifiable and sensitive information have been identified, mapped and risk assessed; technical and organisational measures adequately secure these transfers

2

11-309

Business continuity plans are up to date and tested for all critical information assets (data processing facilities, communications services and data) and service - specific measures are in place

3

11-310

Procedures are in place to prevent information processing being interrupted or disrupted through equipment failure, environmental hazard or human error

2

11-311

Information Assets with computer components are capable of the rapid detection, isolation and removal of malicious code and unauthorised mobile code

2

11-313

Policy and procedures are in place to ensure that Information Communication Technology (ICT) networks operate securely

2

11-314

Policy and procedures ensure that mobile computing and teleworking are secure

3

11-323

All information assets that hold, or are, personal data are protected by appropriate organisational and technical measures

2

11-324

The confidentiality of service user information is protected through use of pseudonymisation and anonymisation techniques where appropriate

2

Clinical Information Assurance 11-400

The Information Governance agenda is supported by adequate information quality and records management skills, knowledge and experience

3

11-401

There is consistent and comprehensive use of the NHS Number in line with National Patient Safety Agency requirements

3

5


Req No


11-402

Procedures are in place to ensure the accuracy of service user information on all systems and /or records that support the provision of care

3

11-404

A multi-professional audit of clinical records across all specialties has been undertaken

2

11-406

Procedures are in place for monitoring the availability of paper health/care records and tracing missing records

2

Secondary Use Assurance 11-501

National data definitions, standards, values and validation programmes are incorporated within key systems and local documentation is updated as standards develop

3

11-502

External data quality reports are used for monitoring and improving data quality

3

11-504

Documented procedures are in place for using both local and national benchmarking to identify data quality issues and analyse trends in information over time, ensuring that large changes are investigated and explained

3

11-505

A robust programme of internal and external data quality/clinical coding audit in line with the requirements of the Audit Commission and NHS Connecting for Health is in place

3

11-506

A documented procedure and a regular audit cycle for accuracy checks on service user data is in place

3

11-507

The Completeness and Validity check for data has been completed and passed

3

11-508

Clinical/care staff are involved in validating information derived from the recording of clinical/care activity

3

11-510

Training programmes for clinical coding staff entering coded clinical data are comprehensive and conform to national standards

3

Corporate Information Assurance 11-601

Documented and implemented procedures are in place for the effective management of corporate records

2

11-603

Documented and publicly available procedures are in place to ensure compliance with the Freedom of Information Act 2000

3

11-604

As part of the information lifecycle management strategy, an audit of corporate records has been undertaken

2

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26th March 2014

THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST REPORT TO: Trust Board REPORT FROM: Toni McConville, Assistant Director

Communications REPORT SPONSORED BY: David Searle, Director of Corporate Development DATE: 26th March 2014 SUBJECT: Corporate Communications Report Trust Strategic Priority: This paper supports achievement of the Trust’s strategic priorities. Summary: This is the second communications report to be presented to the Trust Board. It highlights activity and progress over the last six months, in the period September 2013 to February 2014 as well as outlining key areas of focus for the next period. Board Action Required: The Board is asked to note the report and agree any actions as required Appendices: Appendix 1 - Detail of press release and coverage Appendix 2 - Public website and social media report Equality Impact Assessment: There is no positive or negative impact from this report

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Corporate communications report

Introduction There has been a significant change in the Trust’s approach to communicating with its stakeholders over the last 12 -18 months with an overall shift towards more proactive communications. There has also been a greater focus on strengthening internal communications and a range of effective internal communication channels have been launched. In addition, the last six months has seen a restructure of the Corporate Communications Team resulting in the creation of an Assistant Director level role. This will enable the team to strengthen its strategic communications support to the organisation at a time of great change and opportunity. This report highlights key areas of success, over the last six months, as well as identifying communications activity planned in the coming period. All planned activity outlined is designed to raise awareness and understanding about the aims of the Trust and ensure that its reputation is maintained and enhanced. 1.0 Media coverage Between September 2013 and February 2014, the Communications Team issued 18 media releases to the local media on a broad range of topics with a third of these being taken up. Take-up of releases was largely by the local media. Details of releases and coverage are listed at Appendix 1. Media releases that received particular attention included: the official openings of both the new Fracture Clinic and new Endoscopy Unit at MVH; a visit by QPR football team to Children’s wards; our success at the Patient Experience Network Awards and the opening of the new Macmillan Cancer Information Centre. Many of these stories were published by the Uxbridge Gazette which has a local readership of 96,000. All of our media releases are published on the Trust website and promoted via Twitter. Our ‘Comfort at Night Campaign’ was also positively covered in the Daily Mail and mentioned in a blog by the Secretary of State for Health, Jeremy Hunt. In addition, nine statements have been issued on behalf of the Trust in response to both national and local enquiries. The Team has also successfully changed the emphasis of several potentially negative stories by ensuring that journalists who may have been misled by other sources or, quite simply, got the facts wrong, are given authoritative and credible information from corporate communications. It requires the team to respond very quickly before a story has been worked up into

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an article. This included an enquiry in December from the Daily Telegraph about our Nursing staffing levels. 2.0 Staff engagement As highlighted above, the Team launched a range of new internal communication channels approximately 12 months ago. These include the weekly General Information Bulletin and the CEO channels covered below. The last six months has seen all of these channels become further embedded within the organisation and increasingly gain a high level of recognition amongst Trust staff and other internal stakeholders. The team has also worked closely with other departments on a number of internal engagement campaigns. With the Human Resources Team this has included the continued promotion of Cares values – which has achieved great recognition and understanding (evidenced by the fall in customer complaints due to improvements in staff communication with patients) and the roll-out and promotion of the most recent annual staff survey (which saw the highest number of Trust returns ever submitted). The new Assistant Director has also been able to share in-depth experience and high-level advice on the practicalities on delivering an enhanced Staff Awards event. Other projects supported in the last six months include: Implementation of the new Call Management System; promotion of the NHSLA assessment; introduction of the ESR Learning project and support for the Clinical Quality Strategy. The Team’s support for wider Trust engagement with staff also appears to be bearing fruit as the People and Development division have advised that overall staff engagement has increased to above the national average in the most recent staff survey. 2.1 CEO Messages For the past year, the Communications Team has had editorial control of general information emails issued to all staff. This has significantly reduced the number of such emails and means that those issued have greater impact. To ensure this information has an even greater reach, messages which need to be cascaded to all staff are included in the weekly General Information Bulletin. We continue to issue urgent messages as an all staff email from the Chief Executive. In the last six months these have covered:

• 2013 Staff Survey • Shaping a Healthier Future • Gifts and Hospitality

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• Staff Survey Follow Up • CQC Report • Governor Elections • Comfort at Night (DoN) • End of Year CEO Message • Dr Foster Hospital Guide Awards • Max Earley Press Coverage • Staff Awards 2014

2.2 CEO briefings Organised by the Communications Team, the CEO lunchtime briefing sessions, continue to be an important communication event in the Trust’s calendar. The sessions provide a wider pool of staff the opportunity to hear first-hand from the CEO and his Executive Team about the strategic developments and challenges faced by the organisation. These serve to strengthen understanding and engagement across all staff groups. In the last period these were held at both sites during September, November and January. 2.3 CEO Team Brief Launched in April 2013, Team Brief provides a monthly focus on a specific topic, of organisational importance and provides a temperature test on where we are with strategic priorities and performance. It is distributed to staff via email, published with the General Bulletin and on the intranet. Topics covered from September to February were:

• NHSLA • Staff Survey • Winter Pressures • Shaping a Healthier Future • Priorities for the year ahead • Trust Successes

2.4 CEO staff letter This is produced once every six months and sent to all staff via email as well as posted on staff noticeboards around the hospital sites. The December letter acknowledged the latest Trust achievements and looked ahead to challenges and opportunities facing the organisation in 2014. The next letter will go out in June.

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3.0 Corporate publications The Communications Team works to support the publication of a number of key corporate publications including the Quality Account and the Annual Report. The team is also responsible for managing the production and distribution of The Pulse - The Trust’s quarterly flagship publication. This remains an important tool for the Trust to communicate with its public, staff and FT members providing a wide range of Trust information in an easy-to-read magazine format. The Pulse enables the Trust to communicate its plans with a wider audience and covers: strategic direction, future investment and development; appointment of key Trust people, including Board members and Governors; new initiatives and important information for the public about improvements to services or wider health changes that the Trust needs to implement. Two issues of the magazine have been published since the last report. In the last period, the team has also provided support and guidance to the Marketing Team with the editing, publication and re-launch of GP News. 4.0 Website The Trust’s web presence is crucial for enhancing its engagement with a large audience including the public, patients and health professionals. Between September 2013 and February 2014, the Trust’s website was visited 42,252 times, an increase of 6,238 on the previous six months, with more than half of those viewing the site via a mobile device (mobile phone or tablet). More detail is attached at Appendix 2. Accessing information ‘on the move’ is a growing worldwide trend and the team has worked exceptionally hard, re-designing and reconfiguring page layouts to ensure that the Trust site is increasingly accessible via mobile platforms and therefore attracting more web traffic. The Trust’s Web Developer has also been working on the development of a Content Management System (CMS) for the intranet over the last six months. Once complete and implemented this will enable the internal site to be updated more easily, ensure greater consistency in quality and provide an improved search facility. This will free up the team to concentrate on new areas of development.

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5.0 Twitter The Communications Team launched the Trust’s Twitter account in April 2013. Since that time we have Tweeted 365 times. We have yet to achieve the Trust target of increasing its number of followers to 400 - which currently stands at 281 - but are confident that this is achievable in the near future through publicity in our current avenues of communication and further utilisation of Twitter to cascade information and news. When used appropriately, Twitter is an excellent way of targeting specific interest groups and providing information in real-time. We have had recent success in tweeting information about the latest PIP meeting as well as the opening of the Mount Vernon Endoscopy Unit. More targeted work will be needed to improve engagement through this medium and it is proposed, that among other things, the Communications Team hosts a number of short Twitter information workshops for key Trust groups. These would cover the practicalities of tweeting, increase understanding of the purpose and positive benefits, as well as highlight the potential pitfalls and how to avoid them. 6.0 Supporting major projects In addition to managing the regular communications channels, the Communications Team provides ongoing advice and support to a number of key strategic projects including:

• Emergency care redevelopment • Maternity modernisation • Shaping a Healthier Future • QIPP • Leadership programme • CARES

7.0 Managing Trust events The Team has also effectively managed a number of significant events on behalf of the Trust in the last period. These include:

• Trust's AGM in September 2013 - attended by around 70 people. • Official opening Fracture clinic at Hillingdon Hospital by the Rt Hon John

Randall MP in October – marking a key milestone in the £12.3m Emergency Care Project , which is modernising the hospital. .

• Opening of the Endoscopy unit at Mount Vernon Hospital by Nick Hurd MP in February.

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• Opening of the Macmillan Cancer Information Centre at Hillingdon Hospital by the Mayor of Hillingdon, Councillor Allan Kaufman, at the beginning of March.

8.0 Looking ahead The Trust is facing a particularly challenging period ahead and it is vital that organisational priorities are met through the delivery of the Communications strategy. It is therefore proposed that there is focus on four key areas in the coming year. These are:

• Providing strategic communications support to deliver the SAHF agenda. • Working collaboratively with Business development optimising marketing

opportunities to boost income generation. • Developing an integrated communications strategy to support the QIPP

programme and key transformation projects • Proactively raising the organisation’s profile with a range of key

influencers.

Achieving these goals will require close working with colleagues across the organisation at the earliest stage of project development and their cooperation in identifying key priorities. More general activities planned for the next year include:

• Better utilisation of social media to support Trust activities • Evaluating and strengthening our internal communication channels • Official launch of the new MRI scanner • Official opening of AMU • Official opening on the Maternity Unit • Official Opening of Beaconsfield East.

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Appendix 1

Pro-active media releases September 2013:

• New interactive whiteboards at Hillingdon Hospital • Hillingdon among best London trusts for hip care • Rehabilitation Patients benefit from lottery funding

October:

• Local MP opens new clinic at Hillingdon hospital

November: • Be ‘Health Wise’ this winter – make the right choice for your health care • Hillingdon Hospital wins three teaching awards • Become a Governor for your local Hospitals • Hospital holds Diabetes Day events • Mayor helps celebrate baby care at Hillingdon hospital • Successful glaucoma forum at Hillingdon Hospital

December:

• Hospital donations to the Philippines • Generous donation made to Hillingdon hospital (Bevan Ward donations) • Be ‘Health Wise’ this winter – make the right choice for your health care (joint release

with CCG) • QPR Stars Bring Xmas Cheer to Hospital Children

Jan 2014:

• Hillingdon Hospital Highly Commended by Dr Foster • Become a Governor for your local Hospitals

Feb 2014:

• Hillingdon’s CARES values recognised by patient awards • Hillingdon Hospital continue fundraising for the Philippines typhoon appeal

March 2014 to date:

• Hospital’s children’s menu has all the right ingredients • New cancer information centre opens at Hillingdon hospital • New Endoscopy Unit at Mount Vernon Hospital

Media coverage

September 2013: • Hi-Tech help for patients (Release – Rehabilitation Patients benefit from lottery

funding) • Patient demands an apology for agony (Patient contacted Gazette – statement

provided) • Hospital Radio’s 100 hour broadcast (Radio press release) • Keeping in step with dementia (Gazette at event – Alzheimer’s walk)

October: • Interactive whiteboards for Hillingdon (Release – New interactive whiteboards at

Hillingdon Hospital)

• Patient data loss breaches rules (Statement provided) • Hospital care has changed my mind (Letter) • MP Impressed with cracking new clinic (Release - Local MP opens new clinic at

Hillingdon hospital)

November: • A&E misses out on winter cash (Statement provided) • A&E fails waiting targets (Statement provided) • Elections for vital NHS role (Release - Become a Governor for your local

Hospitals) • NHS wards that 80 per cent wouldn't recommend – Daily Mail (mention of our

Comfort at Night campaign) • How the Government Is Helping the NHS Become Safer (Comfort at Night

mentioned in Blog by Jeremy Hunt)

December: • Hospital parking fees are immoral (Letter) • Man died from heart condition (Result of coroner’s inquest) • Malnutrition cases up by nearly half (Hillingdon Hospital mentioned within article) • Be practical about your Health (Release - Be ‘Health Wise’ this winter – make the

right choice for your health care) • Builders Van Broken into while he visits terminally ill mum at Hospital (statement

provided) • Hoops Stars Bring Christmas Cheer to Hospital Children (Release - QPR Stars

Bring Xmas Cheer to Hospital Children)

Jan 2014: • Hospital disputes fire alarm figures - Uxbridge Gazette GetWestLondon.co.uk

(Statement provided) • Boy, two, died after his brain tumour went undiagnosed for several weeks despite

being seen by doctors in two hospitals – Daily Mail, Mirror, Metro, BBC News, Sky News, Daily Star, GetWestLondon.co.uk (Statement provided)

• Midwife hard pushed to work after break in - Uxbridge Gazette

Feb 2014: • Strategy for using extra NHS money - Uxbridge Gazette • Bill Bailey's Men United appeal echoed in Uxbridge meeting 'all men should attend' -

GetWestLondon.co.uk (article refers to PIP meeting)

March 2014 to date: • As photos show how 70 tumours in one patient vanished in 12 weeks... The anti-

cancer missiles that target tumours chemo can no longer defeat - DailyMail.co.uk (Hillingdon Hospital Mentioned)

• Increase in private ambulances causes problems for Trust – HSJ- (Statement Provided)

• Private ambulances at Hillingdon Hospital putting a strain on A&E - GetWestLondon.co.uk (Statement Provided)

• Macmillan Cancer Support opens centre at Hillingdon Hospital - GetWestLondon.co.uk – (Release - New cancer information centre opens at Hillingdon hospital)

Public website and

social media report September 2013 - February 2014

Our Twitter statistics

365

TWEETS (TOTAL)

101

FOLLOWING (TOTAL)

281

FOLLOWERS (TOTAL)

September 2013: 146 followers

February 2014: 281 followers (92% increase)

21,698 people visited this site (up from 17,656 in previous period)

Around 3,600 a month

The site was visited 42,252 times (up from 36,014 in previous period) Around 7,540 a month

Visits on mobile (including tablet): 23,012 (up from 16,508 in previous period)

Most visited pages – Top 10

Service pages visited – Top 10

% change from last period

Up 10%

Up 32%

Up 26%

Up 19%

Up 24%

Up 50%

Up 19%

Up 16%

Up 70%

0%


26th March 2014


REPORT TO: Trust Board REPORT FROM: Board Committee Chairs DATE: 26th March 2014 SUBJECT: Report from the Charitable Funds Committee Trust Strategic Priority: The Board Committees support the achievement of all of the Trust’s Strategic Priorities. Summary: This report briefs the Board on the meeting of the Charitable Funds Committee held on 3rd March 2014. Board Action Required: This Board is asked to note the issues highlighted in the report and agree any further action as required. Equality Impact Assessment: N/A – there is no positive or negative impact from this report

Charitable Funds Committee 1. The Charitable Funds Committee met on 3rd March 2014. The Board is

asked to note the following report on the key issues that were discussed by the Committee.

2. The Committee reviewed the income and expenditure report for the funds

held on trust for the first nine months of the financial year 2013/14. During this period there was expenditure of £46k against income of £26k. The highest category of expenditure continued to be ‘patient welfare and amenities’. At the end of this period the balance of funds held by the charity is £595k, which in line with the Committee’s objectives represents a reduction in the total balances held compared to the previous quarter. The Committee agreed that the Assistant Directors of Operations should be asked to ensure this trend continues and that funds in their Divisions are spent in line with the charity’s aims in a timely manner.

3. The Committee reviewed a report on the performance of the Charity’s

investments and were pleased to note that the rate of return being achieved is currently exceeding the market benchmark. The Committee agreed the investment charges for the investment services.

4. The Committee approved an updated financial procedure for funds held on trust. The revised document clarifies the way that charitable funds are to be managed including the process for receiving donations and this income being used in line with the charity’s aims.

5. The Committee held a follow-up discussion on whether the charity should adopt a more proactive approach to fundraising by appointing a professional fundraiser. It was noted that such a shift would require commitment from the organisation if it were to be successful and therefore it was agreed that the matter would be discussed further by Board members at a Strategy Session.

6. The Committee thanked Mike Robinson for chairing the Committee and

noted that a new Committee chair would be required when Mike leaves the Trust shortly.

7. The Committee’s next meeting is scheduled for Monday 14th July 2014.

Mike Robinson, Trust Chair Charitable Funds Committee Chair


26th March 2014


REPORT TO: Trust Board REPORT FROM: Mike Robinson, Trust Chair DATE: 26th March 2014 SUBJECT: Revised Committee Membership Trust Strategic Priority(s): N/A Summary: Under the Trust’s Scheme of Reservation and Delegation, the Board is responsible for the appointment of its members to the Board Committees. Attached is the proposed membership of the Board Committees from 1st April 2014, which is presented for the Board’s approval. It is proposed that James Reid chairs the April meeting of the Quality & Risk Committee for purposes of continuity given his involvement in setting up the agenda for the meeting, and that the change in Committee chair takes place following that meeting. The proposed membership is based on James Reid’s appointment as Interim Chair at the Council of Governors meeting on 19th March 2014. Board Action Required: The Board is asked to agree the revised Committee membership with effect from 1st April 2014. Equality Impact Assessment: N/A – there is no positive or negative impact from this report.

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Board Committee membership – from 1st March 2014

Audit & Assurance Committee Katey Adderley Committee Chair, Non-Executive Director Pradip Patel Non-Executive Director Craig Rowland Non-Executive Director Charitable Funds Committee James Reid Committee Chair, Interim Trust Chair Katey Adderley Non-Executive Director Carol Bode Non-Executive Director Theresa Murphy Executive Director of the Patient Experience & Nursing Paul Wratten Finance Director Quality and Risk Committee Carol Bode Committee Chair, Non-Executive Director Katey Adderley Non-Executive Director Soraya Dhillon Non-Executive Director Richard Grocott Mason / Abbas Khakoo

Medical Director

Karl Munslow Ong Chief Operating Officer Theresa Murphy Executive Director of the Patient Experience & Nursing Lis Paice Non-Executive Director David Searle Executive Director for Corporate Development Claire Gore* Director of People * in attendance Trust Transformation Committee Craig Rowland Committee Chair, Non-Executive Director Pradip Patel Non-Executive Director Shane DeGaris Chief Executive Richard Grocott Mason / Abbas Khakoo

Medical Director

Theresa Murphy Executive Director of the Patient Experience & Nursing Lis Paice Non-Executive Director James Reid Interim Trust Chair Claire Gore* Director of People David Searle* Executive Director of Corporate Development Paul Wratten* Finance Director * in attendance Board of Directors Nominations Committee James Reid Committee Chair, Interim Trust Chair Katey Adderley Non-Executive Director Carol Bode Non-Executive Director Shane DeGaris Chief Executive* Soraya Dhillon Non-Executive Director Lis Paice Non-Executive Director Pradip Patel Non-Executive Director

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Craig Rowland Non-Executive Director * The Chief Executive will not be a member of the Nominations Committee when it is dealing with the appointment or removal of the Chief Executive. Board of Directors Remuneration Committee Pradip Patel Committee Chair, Non-Executive Director Katey Adderley Non-Executive Director Carol Bode Non-Executive Director Soraya Dhillon Non-Executive Director Lis Paice Non-Executive Director James Reid Interim Trust Chair Craig Rowland Non-Executive Director

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